A couple has delivered a 28-week fetal demise. Which of the following nursing actions are appropriate to take?Select one that doesn't apply
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Question 2 of 108
The nurse is providing care to a patient 2 hours after a cesarean birth. In the hand-off report, he preceding nurse indicated that the patient's lochia was scant rubra. On initial assessment, the oncoming nurse notes the patient's peripad is saturated with lochia rubra immediately after breastfeeding her infant. What is the nurse's priority action with this finding?
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Question 3 of 108
A mother, 1 day postpartum from a 3-hour labor and a spontaneous vaginal delivery, questions the nurse because her baby's face is"purple."Â Upon examination, the nurse notes petechiae over the scalp, forehead, and cheeks of the baby. The nurse's response should be based on which of the following?
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Question 4 of 108
Four newborns are in the neonatal nursery, none of whom is crying or in distress. Which of the babies should the nurse report to the neonatologist?
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Question 5 of 108
During the first 8 hours postpartum, the nurse will demonstrate how to perform a fundal massage and assist with breast-feeding techniques. What other assessment is important at this time?
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Question 6 of 108
The nurse assesses the fundus and finds it to be boggy, elevated >2 fingerbreadths above the umbilicus, and deviated to one side. What is the common cause of this finding?
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Question 7 of 108
The postpartum nurse is observing a patient holding the baby she delivered less than 24 hours ago. The partner is watching his wife and asking questions about newborn care. The
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Question 8 of 108
During which stage of role attainment do the parents become acquainted with their baby and combine parenting activities with cues from the infant?
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Question 9 of 108
The nurse is developing a plan of care for the patient's fourth stage of labor. One nursing intervention is to promote bonding. Specifically, which nursing action will facilitate the bonding process?
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Question 10 of 108
A woman has just had a macrosomic baby after a 12-hour labor. For which of the following complications should the woman be carefully monitored?
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Question 11 of 108
A 40-week-gestation neonate is in the first period of reactivity. Which of the following actions should the nurse take at this time?
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Question 12 of 108
A woman is receiving Paxil (paroxetine) for postpartum depression. To prevent a drug/food interaction, the client must be advised to refrain from consuming which of the following?
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Question 13 of 108
To reduce the risk of hypoglycemia in a full-term newborn weighing 2,900 grams, what should the nurse do?
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Question 14 of 108
The blood glucose of a client with type 1 diabetes 12 hours after delivery is 96 mg/dL. The client has received no insulin since delivery. The drop in serum levels of which of the following hormones of pregnancy is responsible for the glucose level?
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Question 15 of 108
Which action should the nurse take in order to provide support and encouragement to the new postpartum patient?
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Question 16 of 108
A woman states that she is going to bottle feed her baby because, 'I hate milk and I know that to make good breast milk I will have to drink milk.' The nurse's response about producing high-quality breast milk should be based on which of the following?
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Question 17 of 108
A nurse is caring for the following four laboring patients. Which client should the nurse be prepared to monitor closely for signs of postpartum hemorrhage (PPH)? Select one that doesn't apply
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Question 18 of 108
A neonate is being admitted to the well-baby nursery. Which of the following findings should be reported to the neonatologist?
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Question 19 of 108
What percentage of weight loss did the baby experience? Calculate to the nearest hundredth.
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Question 20 of 108
The nurse does not hear the baby swallow when suckling even though the baby appears to be latched properly to the breast. Which of the following situations may be the reason for this observation?
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Question 21 of 108
A breastfeeding mother who is 2 weeks postpartum is informed by her pediatrician that her 4-year-old has chickenpox (varicella). The mother calls the nursery nurse because she is concerned about having the baby in contact with the sick sibling. The mother had chickenpox as a child. Which of the following responses by the nurse is appropriate?
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Question 22 of 108
The postpartum nurse is reviewing dietary practices for an Asian patient. Which of the following should the nurse expect to observe as a dietary practice for this culture?
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Question 23 of 108
A client's vital signs and reflexes were normal throughout pregnancy, labor, and delivery. Four hours after delivery the client's vitals are 98.6°F, P 72, R 20, BP 150/100, and her reflexes are 4+. She has an intravenous infusion running with 20 units of Pitocin (oxytocin) added. Which of the following actions by the nurse is appropriate?
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Question 24 of 108
A couple is asking the nurse whether or not their son should be circumcised. On which fact should the nurse's response be based?
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Question 25 of 108
A nurse is providing anticipatory guidance to a couple before they take home their newborn. Which of the following should be included?
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Question 26 of 108
A nurse administered RhoGAM to a client whose blood type is A+ (positive). Which of the following responses would the nurse expect to see? Select all that apply.
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Question 27 of 108
Cloxacillin 500 mg by mouth four times per day for 10 days has been ordered for a client with a breast abscess. The client states that she is unable to swallow pills. The oral solution is available as 125 mg/5 mL. How many mL of medicine should the woman take per dose? (Calculate to the nearest whole.)
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Question 28 of 108
A new father calls the nurse's station stating that his wife, who delivered last week, is happy one minute and crying the next. He states, “She was never like this before the baby was born.†How should the nurse best respond?
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Question 29 of 108
To facilitate adequate urinary elimination during the postpartum period, the nurse should incorporate which intervention into the plan of care?
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Question 30 of 108
The nurse is caring for a couple who are in the labor/delivery room immediately after the delivery of a dead baby who exhibited visible birth defects. Which of the following actions by the nurse is appropriate?
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Question 31 of 108
The nurse administers RhoGAM to a postpartum client. Which of the following is the goal of the medication?
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Question 32 of 108
A 2-day-old, exclusively breastfed baby is to be discharged home. Under what conditions should the nurse teach the parents to call the pediatrician?
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Question 33 of 108
The postpartum nurse has completed discharge teaching for a patient being discharged after an uncomplicated vaginal birth. Which statement by the patient indicates that further teaching is necessary?
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Question 34 of 108
The nurse is performing a postpartum assessment on a client who delivered 4 hours ago. The nurse notes a firm uterus at the umbilicus with heavy lochial flow. Which of the following nursing actions is appropriate?
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Question 35 of 108
What do ineffective parenting practices put the newborn at risk for?
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Question 36 of 108
Using the Neonatal Infant Pain Scale (NIPS), a nurse is assessing the pain response of a newborn who has just had a circumcision. The nurse is assessing a change in which of the following signs/symptoms? Select all that apply.
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Question 37 of 108
A nurse on the postpartum unit is caring for two postoperative cesarean clients. One client had spinal anesthesia for the delivery and the other client had an epidural. Which of the following complications will the nurse monitor the spinal client for that the epidural client is much less high risk for?
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Question 38 of 108
The nurse is assessing a newborn on admission to the newborn nursery. Which of the following findings should the nurse report to the neonatologist?
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Question 39 of 108
A client who received an epidural for her operative delivery has vomited twice since the surgery. Which of the following prn medications ordered by the anesthesiologist should the nurse administer at this time?
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Question 40 of 108
The nursery nurse is careful to wear gloves when admitting neonates into the nursery. Which of the following is the scientific rationale for this action?
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Question 41 of 108
What physiologic postpartum change occurs because the uterus shrinks in size, resulting in an increase in blood flow?
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Question 42 of 108
A nurse is doing a newborn assessment on a new admission to the nursery. Which of the following actions should the nurse make when evaluating the baby for developmental dysplasia of the hip (DDH)? Select one that doesn't apply
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Question 43 of 108
A client received general anesthesia during her cesarean section 4 hours ago. Which of the following postpartum nursing interventions is important for the nurse to make?
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Question 44 of 108
The nurse is caring for a client, G3 P2002, whose infant has been diagnosed with a treatable birth defect. Which of the following is an appropriate statement for the nurse to make?
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Question 45 of 108
Which symptom would the nurse expect to observe in a postpartum client with a vaginal hematoma?
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Question 46 of 108
A client is 36 hours post-cesarean section. Which of the following assessments would indicate that the client may have a paralytic ileus?
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Question 47 of 108
A physician writes in a breastfeeding mother's chart, 'Ampicillin 500 mg q 6 h po. Baby should be bottle fed until medication is discontinued.' What should be the nurse's next action?
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Question 48 of 108
A gestational diabetic client, who delivered yesterday, is currently on the postpartum unit. Which of the following statements is appropriate for the nurse to make at this time?
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Question 49 of 108
Which assessment finding 24 hours after vaginal birth would indicate a need for further intervention?
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Question 50 of 108
A client just delivered the placenta pictured below. For which of the following complications should the nurse carefully observe the woman?
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Question 51 of 108
The nurse evaluates a postpartum couplet for parent-infant attachment. What finding would be concerning?
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Question 52 of 108
A client has just received Hemabate (carboprost) because of uterine atony not controlled by IV oxytocin. For which of the following side effects of the medication will the nurse monitor this patient? Select one that doesn't apply.
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Question 53 of 108
A mother, G4 P4004, is 15 minutes postpartum. Her baby weighed 4,595 grams at birth. For which of the following complications should the nurse monitor this client?
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Question 54 of 108
A mother, who gave birth 5 minutes ago, states that she would like to breastfeed. The baby's Apgar score is 9/9. Which of the following actions should the nurse perform first?
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Question 55 of 108
A breastfeeding mother calls the obstetrician's office with a complaint of pain in one breast. Upon inspection, a diagnosis of mastitis is made. Which of the following nursing interventions is appropriate?
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Question 56 of 108
Which short-term goal is appropriate for a full-term, breastfeeding neonate?
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Question 57 of 108
A nurse who is called to a client's room notes that the client's cesarean incision has separated. Which of the following actions is the highest priority for the nurse to perform?
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Question 58 of 108
Which of the following behaviors would be applicable to a nursing diagnosis of Risk for Impaired Parenting?
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Question 59 of 108
A postpartum woman has been diagnosed with postpartum psychosis. Which of the following is essential to be included in the family teaching for this client?
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Question 60 of 108
A bottle-feeding mother is providing a return demonstration of how to burp the baby. Which of the following would indicate that the teaching was successful? Select one that doesn't apply
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Question 61 of 108
What theory developed by Ramona Mercer focused on the process of becoming a mother?
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Question 62 of 108
The nurse is discharging five Rh-negative clients from the maternity unit. The nurse knows that the teaching was successful when the client who had which of the following deliveries asks why she must receive a RhoGAM injection? Select one that doesn't apply
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Question 63 of 108
The nurse has provided anticipatory guidance to a couple that has just delivered a baby. Which of the following is an appropriate short-term goal for the care of their new baby?
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Question 64 of 108
A nurse is developing a teaching plan for parents who are taking home their 2-day-old breastfed baby. Which of the following should the nurse include in the plan?
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Question 65 of 108
A rubella nonimmune, breastfeeding client has just received the rubella vaccine. Which of the following side effects should the nurse warn the client about?
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Question 66 of 108
Which site should the nurse use to assess the pulse of a baby?
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Question 67 of 108
A mother asks whether or not she should be concerned that her baby never opens his mouth to breathe when his nose is so small. Which of the following is the nurse's best response?
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Question 68 of 108
A nurse is working on the postpartum unit. Which of the following patients should the nurse assess first?
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Question 69 of 108
Which vaccinations are indicated for the postpartum patient if she does not have immunity? (Select all that apply.)
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Question 70 of 108
A home care nurse is visiting a breastfeeding client who is 2 weeks postdelivery of a 7-lb baby girl over a midline episiotomy. Which of the following findings should take priority?
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Question 71 of 108
Which description best explains the term reciprocal attachment behavior?
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Question 72 of 108
The postpartum person asks for only warm drinks and food. How can the nurse support this cultural tradition?
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Question 73 of 108
A mother calls the nurse to her room because 'My baby's eyes are bleeding.' The nurse notes bright red hemorrhages in the sclerae of both of the baby's eyes. Which of the following actions by the nurse is appropriate at this time?
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Question 74 of 108
Which patient would be most likely to have severe afterbirth pains and request a narcotic analgesic?
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Question 75 of 108
The nurse is teaching the parents of a 1-day-old baby how to give a sponge bath. Which of the following actions should be included?
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Question 76 of 108
The nurse assesses a 2-day postpartum, breastfeeding client. The nurse notes blood on the mother's breast pad and a crack on the mother's nipple. Which of the following actions should the nurse perform at this time?
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Question 77 of 108
To check for the presence of Epstein's pearls, the nurse should assess which part of the neonate's body?
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Question 78 of 108
A nurse massages the atonic uterus of a woman who delivered 1 hour earlier. The nurse identifies the nursing diagnosis: Risk for injury related to uterine atony. Which of the following outcomes indicates that the client's condition has improved?
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Question 79 of 108
The nurse is providing discharge counseling to a woman who is breastfeeding her baby. What should the nurse advise the woman to do if she should palpate tender, hard nodules in her breasts?
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Question 80 of 108
Research has shown that with lesbian parents, the non-birthing person can feel role resentment, exclusion from health-care services, and feelings of neglect. How can the nurse include the non-birthing partner?
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Question 81 of 108
The nurse screens for risk factors such as an infant in the neonatal intensive care unit (NICU), difficulty in role transition, birth complications, unmet social and physical needs, and lack of partner support for what complication?
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Question 82 of 108
A breastfeeding client calls her obstetrician stating that her baby was diagnosed with thrush and that her breasts have become infected as well. Which of the following organisms has caused the baby's and mother's infection?
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Question 83 of 108
A mother is told that she should bottle feed her child for medical reasons. Which of the following maternal disease states are consistent with the recommendation? Select all that apply.
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Question 84 of 108
A postpartum patient asks, “Will these stretch marks ever go away?†Which is the nurse's best response?
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Question 85 of 108
Which patient is more likely to have less stress adjusting to her role as a mother?
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Question 86 of 108
A neonate, who is being admitted into the well-baby nursery, is exhibiting each of the following assessment findings. Which of the findings should the nurse report to the primary health care provider? Select all that apply.
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Question 87 of 108
A client who has been diagnosed with deep vein thrombosis has been ordered to receive 12 units heparin/min. The nurse receives a 500-mL bag of D5W with 20,000 units of heparin added from the pharmacy. At what rate in mL/hr should the nurse set the infusion pump? (Calculate to the nearest whole.)
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Question 88 of 108
A neonate is admitted to the nursery. The nurse makes the following assessments: weight 3,845 grams, head circumference 35 cm, chest circumference 33 cm, positive Ortolani sign, and presence of supernumerary nipples. Which of the assessments should be reported to the health care practitioner?
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Question 89 of 108
The nurse reviews postpartum discharge instructions regarding sexual health. What information is important to review?
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Question 90 of 108
The nurse has administered Benadryl (diphenhydramine) to a post-cesarean client who is experiencing side effects from the parenteral morphine sulfate that was administered 30 minutes earlier. Which of the following actions should the nurse perform following the administration of the drug?
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Question 91 of 108
A woman who wishes to breastfeed advises the nurse that she had a breast reduction one year earlier. Which of the following responses by the nurse is appropriate?
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Question 92 of 108
The nurse is teaching a non–breastfeeding patient measure to suppress lactation. Which information should the nurse include in the teaching session? (Select all that apply.)
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Question 93 of 108
If the rubella vaccine is indicated for a postpartum patient, which instructions should be provided?
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Question 94 of 108
A breastfeeding client is being seen in the emergency department with a hard, red, warm nodule in the upper outer quadrant of her left breast. Her vital signs are: T 104.6°F, P 100, R 20, and BP 110/60. She has a recent history of mastitis and is crying in pain. Which of the following nursing diagnoses is highest priority?
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Question 95 of 108
A client is 1 day post-cesarean section with spinal anesthesia. Even though the nurse advised against it, the client has had the head of her bed in high Fowler's position since delivery. Which of the following complications would the nurse expect to see in relation to the client's action?
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Question 96 of 108
A woman, 26 weeks' gestation, has just delivered a fetal demise. Which of the following nursing actions is appropriate at this time?
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Question 97 of 108
A woman with postpartum depression has been prescribed Zoloft (sertraline) 50 mg daily. Which of the following should the client be taught about the medication?
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Question 98 of 108
A 2-day-postpartum breastfeeding client is complaining of pain during feedings. Which of the following may be causing the pain?
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Question 99 of 108
To assess fundal contraction 6 hours after cesarean birth, which technique should the nurse utilize?
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Question 100 of 108
A client, who had no prenatal care, delivers a 10-lb 10-oz baby boy whose serum glucose result 1 hour after delivery was 20 mg/dL. Based on these data, which of the following tests should the mother have at her 6-week postpartum checkup?
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Question 101 of 108
Which of the following are nursing measures that can promote parent-infant bonding and attachment? (Select all that apply.)
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Question 102 of 108
A breastfeeding mother mentions to the nurse that she has heard that babies sleep better at night if they are given a small amount of rice cereal in the evening. Which of the following comments by the nurse is appropriate?
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Question 103 of 108
A client is 10 minutes postpartum from a forceps delivery of a 4,500-gram neonate with a cleft lip. The physician performed a right mediolateral episiotomy during the delivery. The client is at risk for each of the following nursing diagnoses. Which of the diagnoses is highest priority at this time?
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ATI RN · Postpartum Body Changes
Question 104 of 108
Which fundal assessment finding at 12 hours after birth requires further assessment?
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ATI RN · Postpartum Body Changes
Question 105 of 108
The home health nurse is visiting a client with HIV who is 6 weeks postdelivery. Which of the following findings would indicate that patient teaching by the nurse in the hospital was successful?
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ATI RN · Postpartum Body Changes
Question 106 of 108
A nurse is providing discharge teaching to the parents of a newborn. Which of the following should be included when teaching the parents how to care for the baby's umbilical cord?
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ATI RN · Postpartum Body Changes
Question 107 of 108
Which of the following drawings is consistent with a baby who was in the frank breech position in utero?
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ATI RN · Postpartum Body Changes
Question 108 of 108
The nurse educates the postpartum person on bowel discomfort. What instructions would they give?
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