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A nurse is preparing to assess the uterine fundus of a client in the immediate
postpartum period. After locating the fundus, the nurse notes that the uterus feels
soft and boggy. Which nursing intervention would be most appropriate?
A. Elevate the client's legs.
B. Massage the fundus until it is firm.
C. Ask the client to turn on her left side.
D. Push on the uterus to assist in expressing clots. - ANSWER ✓ B
The nurse is preparing a list of self-care instructions for a postpartum client who
was diagnosed with mastitis. Which instructions should be included on the list?
Select all that apply.
A. Wear a supportive bra.
B. Rest during the acute phase.
C. Maintain a fluid intake of at least 3000 mL.
D. Continue to breast-feed if the breasts are not too sore.
E. Take the prescribed antibiotics until the soreness subsides.
F. Avoid decompression of the breasts by breast-feeding or breast pump. -
ANSWER ✓ A, B, C, D
, The nurse is providing instructions about measures to prevent postpartum mastitis
to a client who is breast-feeding her newborn. Which client statement would
indicate a need for further instruction?
A. "I should breast-feed every 2 to 3 hours."
B. "I should change the breast pads frequently."
C. "I should wash my hands well before breast-feeding."
D. "I should wash my nipples daily with soap and water." - ANSWER ✓ D
The nurse is assessing a client in the fourth stage of labor and notes that the fundus
is firm, but that bleeding is excessive. Which should be the initial nursing action?
A. Record the findings.
B. Massage the fundus.
C. Notify the health care provider (HCP).
D. Place the client in Trendelenburg's position. - ANSWER ✓ C
The nurse assisted with the delivery of a newborn. Which nursing action is most
effective in preventing heat loss by evaporation?
A. Warming the crib pad
B. Closing the doors to the room
C. Drying the infant with a warm blanket
D. Turning on the overhead radiant warmer - ANSWER ✓ C
The nurse in a neonatal intensive care nursery (NICU) receives a telephone call to
prepare for the admission of a 43-week gestation newborn with Apgar scores of 1
and 4. In planning for admission of this newborn, what is the nurse's highest
priority?
A. Turn on the apnea and cardiorespiratory monitors.
, B. Connect the resuscitation bag to the oxygen outlet.
C. Set up the intravenous line with 5% dextrose in water.
D. Set the radiant warmer control temperature at 36.50 C (97.6° F). - ANSWER ✓
B
The nurse in a newborn nursery is monitoring a preterm newborn for respiratory
distress syndrome. Which assessment findings would alert the nurse to the
possibility of this syndrome?
A. Tachypnea and retractions
B. Acrocyanosis and grunting
C. Hypotension and bradycardia
D. Presence of a barrel chest and acrocyanosis - ANSWER ✓ A
The postpartum nurse is providing instructions to the mother of a newborn with
hyperbilirubinemia who is being breast-fed. The nurse should provide which most
appropriate instruction to the mother?
A. Feed the newborn less frequently.
B. Continue to breast-feed every 2 to 4 hours.
C. Switch to bottle-feeding the infant for 2 weeks.
D. Stop breast-feeding and switch to bottle-feeding Permanently. - ANSWER ✓ B
The nurse implements a teaching plan for a pregnant client who is newly
diagnosed with gestational diabetes mellitus. Which statement made by the client
indicates a need for further teaching?
A. "I should stay on the diabetic diet."
B. "I should perform glucose monitoring at home."
C. "I should avoid exercise because of the negative effects on insulin production."