Ricci Chapter 15 - Test Bank - 4th Edition
questions and answers already passed
1. A primipara client gave birth vaginally to a healthy newborn girl 12 hours ago. The nurse
palpates the client's fundus. Which finding would the nurse identify as expected?
A. two fingerbreadths above the umbilicus
B. at the level of the umbilicus
C. two fingerbreadths below the umbilicus
D. four fingerbreadths below the umbilicus - correct answer ✔✔Answer: B
Rationale: During the first 12 hours postpartum, the fundus of the uterus is located at the level
of
the umbilicus. Over the first few days after birth, the uterus typically descends from the level of
the umbilicus at a rate of 1 cm (one fingerbreadth) per day. By 3 days, the fundus lies two to
three fingerbreadths below the umbilicus (or slightly higher in multiparous women). By the end
of 10 days, the fundus usually cannot be palpated because it has descended into the true pelvis.
2. When caring for a mother who has had a cesarean birth, the nurse would expect the client's
lochia to be:
A. greater than after a vaginal birth.
B. about the same as after a vaginal birth.
C. less than after a vaginal birth.
D. saturated with clots and mucus. - correct answer ✔✔Answer: C
Rationale: Women who have had cesarean births tend to have less flow because the uterine
debris is removed manually along with delivery of the placenta.
,3. The nurse is developing a teaching plan for a client who has decided to bottle-feed her
newborn. Which information would the nurse include in the teaching plan to facilitate
suppression of lactation?
A. encouraging the woman to manually express milk
B. suggesting that she take frequent warm showers to soothe her breasts
C. telling her to limit the amount of fluids that she drinks
D. instructing her to apply ice packs to both breasts every other hour - correct answer
✔✔Answer: D
Rationale: If the woman is not breastfeeding, relief measures for engorgement include wearing
a
tight supportive bra 24 hours daily, applying ice to her breasts for approximately 15 to 20
minutes every other hour, and not stimulating her breasts by squeezing or manually expressing
milk. Warm showers enhance the let-down reflex and would be appropriate if the woman was
breastfeeding. Limiting fluid intake is inappropriate. Fluid intake is important for all postpartum
women, regardless of the feeding method chosen.
4. The nurse is making a follow-up home visit to a woman who is 12 days postpartum. Which
finding would the nurse expect when assessing the client's fundus?
A. cannot be palpated
B. 2 cm below the umbilicus
C. 6 cm below the umbilicus
D. 10 cm below the umbilicus - correct answer ✔✔Answer: A
Rationale: By the end of 10 days, the fundus usually cannot be palpated because it has
descended
into the true pelvis.
, 5. A client who is breastfeeding her newborn tells the nurse, "I notice that when I feed him, I
feel
fairly strong contraction-like pain. Labor is over. Why am I having contractions now?" Which
response by the nurse would be most appropriate?
A. "Your uterus is still shrinking in size; that's why you're feeling this pain."
B. "Let me check your vaginal discharge just to make sure everything is fine."
C. "Your body is responding to the events of labor, just like after a tough workout."
D. "The baby's sucking releases a hormone that causes the uterus to contract." - correct answer
✔✔Answer: D
Rationale: The woman is describing afterpains, which are usually stronger during breastfeeding
because oxytocin released by the sucking reflex strengthens uterine contractions. Afterpains are
associated with uterine involution, but the woman's description strongly correlates with the
hormonal events of breastfeeding. All women experience afterpains, but they are more acute in
multiparous women secondary to repeated stretching of the uterine muscles.
6. When the nurse is assessing a postpartum client approximately 6 hours after birth, which
finding would warrant further investigation?
A. deep red, fleshy-smelling lochia
B. voiding of 350 cc
C. blood pressure 90/50 mm Hg
D. profuse sweating - correct answer ✔✔Answer: C
Rationale: In most instances of postpartum hemorrhage, blood pressure and cardiac output
remain increased because of the compensatory increase in heart rate. Thus, a decrease in blood
pressure and cardiac output are not expected changes during the postpartum period. Early
identification is essential to ensure prompt intervention. Deep red, fleshy-smelling lochia is a
normal finding 6 hours postpartum. Voiding in small amounts such as less than 150 cc would
indicate a problem, but 350 cc would be appropriate. Profuse sweating also is normal during the
questions and answers already passed
1. A primipara client gave birth vaginally to a healthy newborn girl 12 hours ago. The nurse
palpates the client's fundus. Which finding would the nurse identify as expected?
A. two fingerbreadths above the umbilicus
B. at the level of the umbilicus
C. two fingerbreadths below the umbilicus
D. four fingerbreadths below the umbilicus - correct answer ✔✔Answer: B
Rationale: During the first 12 hours postpartum, the fundus of the uterus is located at the level
of
the umbilicus. Over the first few days after birth, the uterus typically descends from the level of
the umbilicus at a rate of 1 cm (one fingerbreadth) per day. By 3 days, the fundus lies two to
three fingerbreadths below the umbilicus (or slightly higher in multiparous women). By the end
of 10 days, the fundus usually cannot be palpated because it has descended into the true pelvis.
2. When caring for a mother who has had a cesarean birth, the nurse would expect the client's
lochia to be:
A. greater than after a vaginal birth.
B. about the same as after a vaginal birth.
C. less than after a vaginal birth.
D. saturated with clots and mucus. - correct answer ✔✔Answer: C
Rationale: Women who have had cesarean births tend to have less flow because the uterine
debris is removed manually along with delivery of the placenta.
,3. The nurse is developing a teaching plan for a client who has decided to bottle-feed her
newborn. Which information would the nurse include in the teaching plan to facilitate
suppression of lactation?
A. encouraging the woman to manually express milk
B. suggesting that she take frequent warm showers to soothe her breasts
C. telling her to limit the amount of fluids that she drinks
D. instructing her to apply ice packs to both breasts every other hour - correct answer
✔✔Answer: D
Rationale: If the woman is not breastfeeding, relief measures for engorgement include wearing
a
tight supportive bra 24 hours daily, applying ice to her breasts for approximately 15 to 20
minutes every other hour, and not stimulating her breasts by squeezing or manually expressing
milk. Warm showers enhance the let-down reflex and would be appropriate if the woman was
breastfeeding. Limiting fluid intake is inappropriate. Fluid intake is important for all postpartum
women, regardless of the feeding method chosen.
4. The nurse is making a follow-up home visit to a woman who is 12 days postpartum. Which
finding would the nurse expect when assessing the client's fundus?
A. cannot be palpated
B. 2 cm below the umbilicus
C. 6 cm below the umbilicus
D. 10 cm below the umbilicus - correct answer ✔✔Answer: A
Rationale: By the end of 10 days, the fundus usually cannot be palpated because it has
descended
into the true pelvis.
, 5. A client who is breastfeeding her newborn tells the nurse, "I notice that when I feed him, I
feel
fairly strong contraction-like pain. Labor is over. Why am I having contractions now?" Which
response by the nurse would be most appropriate?
A. "Your uterus is still shrinking in size; that's why you're feeling this pain."
B. "Let me check your vaginal discharge just to make sure everything is fine."
C. "Your body is responding to the events of labor, just like after a tough workout."
D. "The baby's sucking releases a hormone that causes the uterus to contract." - correct answer
✔✔Answer: D
Rationale: The woman is describing afterpains, which are usually stronger during breastfeeding
because oxytocin released by the sucking reflex strengthens uterine contractions. Afterpains are
associated with uterine involution, but the woman's description strongly correlates with the
hormonal events of breastfeeding. All women experience afterpains, but they are more acute in
multiparous women secondary to repeated stretching of the uterine muscles.
6. When the nurse is assessing a postpartum client approximately 6 hours after birth, which
finding would warrant further investigation?
A. deep red, fleshy-smelling lochia
B. voiding of 350 cc
C. blood pressure 90/50 mm Hg
D. profuse sweating - correct answer ✔✔Answer: C
Rationale: In most instances of postpartum hemorrhage, blood pressure and cardiac output
remain increased because of the compensatory increase in heart rate. Thus, a decrease in blood
pressure and cardiac output are not expected changes during the postpartum period. Early
identification is essential to ensure prompt intervention. Deep red, fleshy-smelling lochia is a
normal finding 6 hours postpartum. Voiding in small amounts such as less than 150 cc would
indicate a problem, but 350 cc would be appropriate. Profuse sweating also is normal during the
