Exam (elaborations) NURS 1102 PASSPOINT POSTPARTUM

NURS 1102 PASSPOINT POSTPARTUM Question 1 See full question A client gives birth to a stillborn neonate at 36 weeks' gestation. When caring for this client, which strategy by the nurse would be most helpful? You Selected: • Provide information about possible causes of the stillbirth only if the client requests it. Correct response: • Encourage the client to see, touch, and hold the dead neonate. Explanation: Remediation: Question 2 See full question During the postpartum period, a nurse should assess for signs of normal involution. Which statement would indicate that a client is progressing normally? You Selected: • Perineal pad usage remains at 10 to 15 per day. Correct response: • The uterus is descending at the rate of one fingerbreadth per day. Explanation: Remediation: Question 3 See full question Which response would be most appropriate for the nurse when comforting a primiparous client whose critically ill neonate delivered at 25 weeks dies while the mother is present? You Selected: • "You can stay with your baby as long as you want and say anything you want." Correct response: NURS 1102 PASSPOINT POSTPARTUM • "You can stay with your baby as long as you want and say anything you want." Explanation: Remediation: Question 4 See full question While the nurse is caring for a primiparous client on the first postpartum day, the client asks, “How is that woman doing who lost her baby from prematurity? We were in labor together.” Which response by the nurse would be most appropriate? You Selected: • Tell the client “I’m not sure how the other woman is doing today.” Correct response: • Explain to the client that “Nurses are not allowed to discuss other clients on the unit.” Explanation: Remediation: Question 1 See full question A client gave birth to a healthy full-term girl 2 hours ago by cesarean birth. When assessing this client, which finding requires immediate nursing action? You Selected: • Tachycardia and hypotension Correct response: • Tachycardia and hypotension Explanation: Remediation: Question 2 See full question Lochia normally progresses in which pattern? You Selected: • Rubra, serosa, alba Correct response: • Rubra, serosa, alba Explanation: Remediation: Question 3 See full question A client who had a cesarean birth 1 day ago asks for pain medication when the nurse enters the room to perform her shift assessment. The client states that her pain level is an 8 on a 0-to-10-point scale. The priority of care should be for the nurse to: You Selected: • administer any ordered pain medication. Correct response: • administer any ordered pain medication. Explanation: Remediation: Question 4 See full question While the nurse is caring for a primiparous client on the first postpartum day, the client asks, “How is that woman doing who lost her baby from prematurity? We were in labor together.” Which response by the nurse would be most appropriate? You Selected: • Explain to the client that “Nurses are not allowed to discuss other clients on the unit.” Correct response: • Explain to the client that “Nurses are not allowed to discuss other clients on the unit.” Explanation: Remediation: Question 5 See full question While changing the neonate’s diaper, the client asks the nurse about some red-tinged drainage from the neonate’s vagina. Which response would be most appropriate? You Selected: • “Sometimes baby girls have this from hormones received from the mother.” Correct response: • “Sometimes baby girls have this from hormones received from the mother.” Explanation: Remediation: Question 5 See full question While making a home visit to a multigravida 2 weeks after the birth of viable twins at 38 weeks’ gestation, the nurse observes that the client looks pale, has dark circles around her eyes, and is breastfeeding one of the twins. The client’s apartment is clean, and nothing appears out of place. The client tells the nurse that she completed three loads of laundry this morning. A priority need for this client is: You Selected: • possible anemia related to large volume of blood loss and twin birth. Correct response: • fatigue related to home maintenance and caring for twins. Explanation: /.modal - - - - - - - - - - - - - - - - - - - - - - - - Footer - - - - - - - - - - - - - - - - - - - - - - - - - TAKE A PRACTICE QUIZ Question 1 See full question A client is at the end of her first postpartum day. The nurse is assessing the client's uterus. Which finding requires further evaluation? You Selected:  Fundus two fingerbreadths above the umbilicus Correct response:  Fundus two fingerbreadths above the umbilicus Explanation: Remediation: Question 2 See full question A nurse is assessing the parent-neonate attachment of postpartum clients. Which finding most indicates a need for further evaluation? You Selected:  Limited parent-neonate contact immediately after birth Correct response:  Limited parent-neonate contact immediately after birth Explanation: Remediation: Question 3 See full question A nurse encourages a postpartum client to discuss the childbirth experience. Which client outcome is most appropriate for this client? You Selected:  "The client demonstrates an understanding of the neonate's physical needs related to labor and birth." Correct response:  "The client demonstrates the ability to integrate the childbirth experience and progress to the task of maternal role attainment." Explanation: Remediation: Question 4 See full question Lochia normally progresses in which pattern? You Selected:  Rubra, serosa, alba Correct response:  Rubra, serosa, alba Explanation: Remediation: Question 5 See full question When caring for a multiparous client who is human immunodeficiency virus (HIV)–positive and asking to breastfeed her neonate as soon as possible, which information about breast milk should the nurse include in the teaching plan? You Selected:  It has been found to contain the retrovirus HIV. Correct response:  It has been found to contain the retrovirus HIV. Explanation: Remediation: A client who gave birth 24 hours ago continues to experience urine retention after several catheterizations. The physician orders bethanechol, 10 mg by mouth three times per day. The client asks, "How does bethanechol act on the bladder?" How should the nurse respond? You Selected: • "It stimulates the smooth muscle of the bladder." Correct response: • "It stimulates the smooth muscle of the bladder." Explanation: Remediation: Question 2 See full question A nurse is assessing a client on the second postpartum day. Upon palpation, the nurse discovers that the fundus is deviated to the right. To further investigate this finding, what should the nurse ask the client? You Selected: • "Are you having afterpains?" Correct response: • "Have you voided recently?" Explanation: Remediation: Question 3 See full question When caring for a client who has recently given birth, the nurse assesses the client for urinary retention with overflow. Which sign or symptom provides the most accurate picture of retention with overflow? You Selected: • A varying urge to urinate with an average output of 100 ml Correct response: • A varying urge to urinate with an average output of 100 ml Explanation: Remediation: Question 4 See full question When caring for a multiparous client who is human immunodeficiency virus (HIV)–positive and asking to breastfeed her neonate as soon as possible, which information about breast milk should the nurse include in the teaching plan? You Selected: • It has been found to contain the retrovirus HIV. Correct response: • It has been found to contain the retrovirus HIV. Explanation: Remediation: Question 5 See full question A nurse meets his/her neighbor and new baby at the local market. The neighbor states that she received outstanding nursing care from one of the nurse's colleagues during her labor and childbirth. What is the best way for the nurse to recognize her nursing colleague’s professional efforts? You Selected: • Post accolades to the nurse at the nurses’ station. Correct response: • Share the feedback with the nursing colleague directly. Explanation: /.modal - - - - - - - - - - - - - - - - - - - - - - - - Footer - - - - - - - - - - - - - - - - - - - - - - - - - TAKE A PRACTICE QUIZ Question 6 See full question An adolescent primiparous client 24 hours postpartum asks the nurse how often she can hold her baby without “spoiling” him. Which response would be most appropriate? You Selected:  “Hold him as much as you want to hold him.” Correct response:  “Hold him as much as you want to hold him.” Explanation: Remediation: Question 7 See full question While assisting a primiparous client with her first breastfeeding session, which action should the nurse instruct the mother to do to stimulate the neonate to open the mouth and grasp the nipple? You Selected:  Brush the neonate’s lips lightly with the nipple. Correct response:  Brush the neonate’s lips lightly with the nipple. Explanation: Remediation: Question 8 See full question After giving birth to a viable neonate 12 hours ago, the client’s fundus is firm at midline, and her breasts are soft. She has scant lochia and she is voiding sufficiently. The client reports pain in her lower back. What should the nurse do next? You Selected:  Administer a prescribed mild analgesic. Correct response:  Administer a prescribed mild analgesic. Explanation: Remediation: Question 9 See full question A client and her partner just experienced spontaneous bleeding at 11 weeks gestation, which resulted in the loss of the fetus. The couple wonders if the bleeding could have been caused from the client working long hours in a stressful work environment. What is the most appropriate response from the nurse? You Selected:  “I can understand your need to find an answer to what caused this. Let’s talk about this further.” Correct response:  “I can understand your need to find an answer to what caused this. Let’s talk about this further.” Explanation: Remediation: Question 10 See full question The nurse is educating an expectant mother about breastfeeding. What statement made by the mother would prevent the mother from breastfeeding the newborn? You Selected:  “I have been HIV positive for 4 years.” Correct response:  “I have been HIV positive for 4 years.” Question 1 See full question A nurse is teaching a client about hormonal contraceptive therapy. If a client misses three or more pills in a row, the nurse should instruct the client to: You Selected:  take all the missed doses as soon as she discovers the oversight. Correct response:  discard the pack, use an alternative contraceptive method until her period begins, and start a new pack on the regular schedule. Explanation: Remediation: Question 2 See full question During a home visit on the fifth postpartum day, the client begins to cry and says that she is worried about her ability to care for her baby adequately. She tells the nurse, “I wish I could just get organized—I need 8 hours of sleep!” The nurse determines that she is experiencing which condition? You Selected:  Postpartum blues phase of childbearing; she needs psychological counseling. Correct response:  Taking-hold phase of childbearing; she is feeling inadequate about neonatal care. Explanation: Remediation: Question 3 See full question A 24-year-old primipara decides to breastfeed her baby but says, “I am worried that I will not be able to breastfeed my baby because my breasts are so small.” What would the nurse include in the explanation to the client? You Selected:  The woman's motivation to breast-feed is more important than breast size. Correct response:  Breast size poses no influence on a woman's ability to breastfeed a baby. Explanation: Remediation: Question 4 See full question On the first postpartum day after a cesarean birth, the client is prescribed a full liquid diet as tolerated. Before providing a full liquid breakfast, the nurse should assess which factor? You Selected:  desire to eat Correct response:  bowel sounds Explanation: Remediation: Question 5 See full question While assisting a multiparous client to the bathroom for the first time 1 hour after a vaginal birth of a viable neonate, the nurse notes that the client’s urine has two small blood clots in the measuring container. What should the nurse do next? You Selected:  Document this observation as a normal finding. Correct response:  Document this observation as a normal finding. Explanation: Remediation: Question 6 See full question Twenty-four hours after giving birth to a term neonate, a primipara receives acetaminophen with codeine for perineal pain. One hour after administering the medication, which finding should alert the nurse to the development of a possible side effect? You Selected:  dizziness Correct response:  dizziness Explanation: Question 7 See full question Which client statement indicates effective teaching about burping a breastfed neonate? You Selected:  “Breastfed babies who are burped frequently will take more on each breast.” Correct response:  “When I switch to the other breast, I’ll burp the baby.” Explanation: Remediation: Question 8 See full question A nurse is assisting a grieving client and his/her spouse to deal with their loss of their 24-week-old infant. Which of the following actions would be most appropriate from the nurse? Select all that apply. You Selected:  Provide an early opportunity for the couple to see their child if they desire.  Answer the parents’ questions accurately.  Offer to stay with the grieving parents. Correct response:  Provide an early opportunity for the couple to see their child if they desire.  Offer to stay with the grieving parents.  Answer the parents’ questions accurately. Explanation: Remediation: Question 9 See full question A postpartum client tells the nurse that she and her husband had an argument about continuing breastfeeding before he left for work in the morning. He was up all night, not able to sleep with the baby crying, and he wants the client to give the baby formula. What is the most appropriate immediate response from the nurse? You Selected:  “What are your feelings about breastfeeding?” Correct response:  “What are your feelings about breastfeeding?” Explanation: Remediation: Question 1 See full question A client with cardiac disease gives birth. Afterward, the nurse assesses the client for signs and symptoms of cardiac decompensation. During the postpartum period, which assessment finding indicates a need for further investigation? You Selected: • Diuresis Correct response: • Tachycardia Explanation: Remediation: Question 2 See full question Rho (D) immune globulin (RhoGAM) is prescribed for a client before she is discharged after a spontaneous abortion. The nurse instructs the client that this drug is used to prevent which condition? You Selected: • development of Rh-positive antibodies Correct response: • development of Rh-positive antibodies Explanation: Remediation: Question 3 See full question Three hours postpartum, a primiparous client’s fundus is firm and midline. On perineal inspection, the nurse observes a small, constant trickle of blood. Which condition should the nurse assess further? You Selected: • perineal lacerations Correct response: • perineal lacerations Explanation: Remediation: Question 4 See full question The nurse is evaluating the client who gave birth vaginally 2 hours ago and is experiencing postpartum pain rated 8 on scale of 1 to 10. The client is a multigravida breastfeeding mother who would like medication to decrease the pain in her uterus. Which of the medications listed on the prescriptions sheet would be the most appropriate for this client? You Selected: • ibuprofen 800 mg PO every 6 to 8 hour PRN Correct response: • acetaminophen and hydrocodone 10 mg 1 tab PO every 4 to 6 hour PRN Explanation: Remediation: Question 5 See full question A nurse is assisting a grieving client and his/her spouse to deal with their loss of their 24-week-old infant. Which of the following actions would be most appropriate from the nurse? Select all that apply. You Selected: • Answer the parents’ questions accurately. • Offer to stay with the grieving parents. • Provide an early opportunity for the couple to see their child if they desire. Correct response: • Provide an early opportunity for the couple to see their