A client, G1 P0000, is PP1 from a normal spontaneous delivery of a baby boy, Apgar 5/6. Because the client exhibited addictive behaviors, a toxicology assessment was performed; the results were positive for alcohol and cocaine. Which of the following interventions is appropriate for the nurse to perform for this postpartum client?
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Question 2 of 107
A nurse is teaching a mother how to care for her 3-day-old son's circumcised penis. Which of the following actions demonstrates that the mother has learned the information?
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Question 3 of 107
The nurse should expect to observe which behavior in a 3-week-multigravid postpartum client with postpartum depression?
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Question 4 of 107
A client is being discharged on Coumadin (warfarin) post-pulmonary embolism after a cesarean delivery. Which of the following should be included in the patient teaching?
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Question 5 of 107
When assessing the A of the acronym REEDA, the nurse should evaluate the
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Question 6 of 107
A newly delivered mother states, 'I have not had any alcohol since I decided to become pregnant. I have decided not to breastfeed because I would really like to go out and have a good time for a change.' Which of the following is the best response by the nurse?
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Question 7 of 107
The nurse is developing a standard care plan for the post-cesarean client. Which of the following should the nurse plan to implement?
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Question 8 of 107
A mother asks the nurse which powder she should purchase to use on the baby's skin. What should the nurse's response be?
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Question 9 of 107
It is time for a baby who is in the drowsy behavioral state to breastfeed. Which of the following techniques could the mother use to arouse the baby? Select one that doesn't apply
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Question 10 of 107
Research has shown what intervention increases involvement of the adolescent partner postpartum?
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Question 11 of 107
A client is receiving a blood transfusion after the delivery of a placenta accreta and hysterectomy. Which of the following complaints by the client would warrant immediately discontinuing the infusion?
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Question 12 of 107
A client, 1 day postpartum (PP), is being monitored carefully after a significant postpartum hemorrhage. Which of the following should the nurse report to the obstetrician?
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Question 13 of 107
A neonate is in the active alert behavioral state. Which of the following would the nurse expect to see?
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Question 14 of 107
The nurse is providing care to a patient who delivered a 3525-g infant 14 hours ago. The nurse palpates the fundus of the uterus as firm and at the umbilicus. What is the nurse’s priority action related to this finding?
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Question 15 of 107
The nurse is planning comfort measures to implement for a patient after a vaginal birth. Which measures should the nurse plan to include in the patient’s care plan? (Select all that apply.)
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Question 16 of 107
Postpartum persons who lack attachment with their newborn exhibit what behavior?
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Question 17 of 107
Which should the nurse do to provide support to a patient who must return to full-time employment 6 weeks after a vaginal birth?
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Question 18 of 107
The postpartum patient who continually repeats the story of her labor, birth, and recovery experiences is performing which of the following tasks?
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Question 19 of 107
A postpartum client has been diagnosed with deep vein thrombosis. For which of the following additional complications is this client high risk?
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Question 20 of 107
A mother asks the nurse to tell her about the responsiveness of neonates at birth. Which of the following answers is appropriate? Select one that doesn't apply.
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Question 21 of 107
The nurse notes that a newborn, who is 5 minutes old, exhibits the following characteristics: heart rate 108 bpm, respiratory rate 29 rpm with lusty cry, pink body with bluish hands and feet, some flexion. What does the nurse determine the baby's Apgar score is?
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Question 22 of 107
A client is preparing to breastfeed her newborn son in the cross-cradle position. Which of the following actions should the woman make?
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Question 23 of 107
A mucousy baby is being left with the parents for the first time after delivery. Which of the following should the nurse teach the parents regarding use of the bulb syringe?
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Question 24 of 107
What is the nursing intervention for unilateral edema in a lower extremity and a hot, red area on the leg?
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Question 25 of 107
Four pregnant women advise the nurse that they wish to breastfeed their babies. Which of the mothers should be advised to bottle feed her child?
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Question 26 of 107
To promote bonding and attachment immediately after birth, which action should the nurse take?
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Question 27 of 107
A postpartum patient calls the clinic and reports to the nurse feelings of fatigue, tearfulness, and anxiety. What is the nurse’s most appropriate response at this time?
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Question 28 of 107
The nurse is caring for a postpartum patient who delivered by the vaginal route 12 hours ago. Which assessment finding should the nurse report to the health care provider?
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Question 29 of 107
A couple, accompanied by their 5-year-old daughter, have been notified that their 32-week-gestation fetus is dead. The father is yelling at the staff. The mother is crying uncontrollably. The 5-year-old is banging the head of her doll on the floor. Which of the following nursing actions is appropriate at this time?
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Question 30 of 107
Postpartal overdistention of the bladder and urinary retention can lead to which complication?
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Question 31 of 107
A nurse is caring for a client, PP2, who is preparing to go home with her infant. The nurse notes that the client's blood type is O− (negative), the baby's type is A+ (positive), and the direct Coombs' test is negative. Which of the following actions by the nurse is appropriate?
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Question 32 of 107
A breastfeeding baby is born with a tight frenulum. Which of the following is an important assessment for the nurse to make?
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Question 33 of 107
Which maternal event is abnormal in the early postpartal period?
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Question 34 of 107
The nurse notes the following vital signs of a postoperative cesarean client during the immediate postpartum period: 100.0°F, P 68, R 12, BP 130/80. Which of the following is a correct interpretation of the findings?
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Question 35 of 107
The nurse assesses for signs of depression or postpartum blues. How can the nurse explain the difference?
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Question 36 of 107
Which of the following actions would encourage the baby to open the mouth wide for feeding?
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Question 37 of 107
A 2-day-old breastfeeding baby born via normal spontaneous vaginal delivery has just been weighed in the newborn nursery. The nurse determines that the baby has lost 3.5% of the birth weight. Which of the following nursing actions is appropriate?
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Question 38 of 107
A full-term newborn was just born. Which nursing intervention is important for the nurse to perform first?
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Question 39 of 107
A client has been receiving magnesium sulfate for severe preeclampsia for 12 hours. Her reflexes are 0 and her respiratory rate is 10. Which of the following situations could be a precipitating factor in these findings?
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Question 40 of 107
A client is receiving an IV heparin drip at 16 mL/hr via an infusion pump for a diagnosis of deep vein thrombosis. The label on the 1/2 liter bag of D5W indicates 25,000 units of heparin have been added. How many units of heparin is the client receiving per hour? (Calculate to the nearest whole.)
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Question 41 of 107
The nurse observes a patient on her first postpartum day sitting in bed while her newborn lies awake in the bassinet. Which action is most appropriate for the nurse to take at this time?
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Question 42 of 107
The nurse is concerned that a bottle-fed baby may become obese because of which activity by the mother?
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Question 43 of 107
A client, who is 2 weeks postpartum, calls her obstetrician's nurse and states that she has had a whitish discharge for 1 week but today she is"bleeding and saturating a pad about every 1/2 hour."Which of the following is an appropriate response by the nurse?
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Question 44 of 107
Before taking the newborn's vital signs, the nurse should warm his or her hands and the stethoscope to prevent heat loss resulting from which of the following?
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Question 45 of 107
A breastfeeding woman calls the pediatric nurse with the following complaint:"I woke up this morning with a terrible cold. I don't want my baby to get sick. Which kind of formula should I have my husband feed the baby until I get better?" Which of the following replies by the nurse is appropriate at this time?
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Question 46 of 107
What type of lochia is bright to dark red and occurs on days 1–3 postpartum?
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Question 47 of 107
Which measure is optimal in order to prevent abdominal distention following a cesarean birth?
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Question 48 of 107
The nursery charge nurse is assessing a 1-day-old female on morning rounds. Which of the following findings should be reported to the neonatologist as soon as possible? Select all that apply.
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Question 49 of 107
A family is concerned about how their 2-year-old son is going to react to the new baby. Which intervention would help facilitate sibling attachment?
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Question 50 of 107
Intermittent positive pressure boots have been ordered for a client who had an emergency cesarean section. Which of the following is the rationale for that order?
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Question 51 of 107
The nurse includes the addition of ice sitz baths for the postpartum patient. Which assessment finding indicates the treatment has been effective?
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Question 52 of 107
The pediatrician has ordered vitamin K 0.5 mg IM for a newborn. The medication is available as 2 mg/mL. How many milliliters (mL) should the nurse administer to the baby? Calculate to the nearest hundredth.
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Question 53 of 107
A postpartum woman has been diagnosed with postpartum psychosis. Which of the following signs/symptoms would the client exhibit?
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Question 54 of 107
A client is to receive a blood transfusion after significant blood loss following a placenta previa delivery. Which of the following actions by the nurse is critical prior to starting the infusion? Select all that apply.
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Question 55 of 107
A nurse notes that a 6-hour-old neonate has cyanotic hands and feet. Which of the following actions by the nurse is appropriate?
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Question 56 of 107
The nurse educates the non–breast-feeding person on breast discomfort caused by engorgement. What instructions would they give?
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Question 57 of 107
A postoperative cesarean client, who was diagnosed with severe preeclampsia in labor and delivery, is transferred to the postpartum unit. The nurse is reviewing the client's doctor's orders. Which of the following medications that were ordered by the doctor should the nurse question?
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Question 58 of 107
During which phase of maternal adjustment will the mother relinquish the baby of her fantasies and accept the real baby?
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Question 59 of 107
The physician declares after delivering the placenta of a client during a cesarean section that it appears that the client has a placenta accreta. Which of the following maternal complications would be consistent with this diagnosis?
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Question 60 of 107
The nurse is caring for a postoperative cesarean client. The woman is obese and is an insulin-dependent diabetic. For which of the following complications should the nurse carefully monitor this client?
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Question 61 of 107
The nurse is conducting discharge teaching for a patient going home after a cesarean birth. Which signs and symptoms should the patient be taught to report? (Select all that apply.)
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Question 62 of 107
A client has given birth to a baby girl with a visible birth defect. Which of the following maternal responses would lead the nurse to suspect poor mother-infant bonding?
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Question 63 of 107
The nurse is about to elicit the Moro reflex. Which of the following responses should the nurse expect to see?
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Question 64 of 107
In which of the following situations should a nurse report a possible deep vein thrombosis (DVT)?
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Question 65 of 107
A baby boy is to be circumcised by the mother's obstetrician. Which of the following actions shows that the nurse is being a patient advocate?
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Question 66 of 107
On admission to the maternity unit, it is learned that a mother has smoked 2 packs of cigarettes per day and expects to continue to smoke after discharge. The mother also states that she expects to breastfeed her baby. The nurse's response should be based on which of the following?
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Question 67 of 107
Which of the following full-term babies requires immediate intervention?
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Question 68 of 107
The person with a cesarean birth has additional nursing concerns beyond those of a person with a vaginal birth. What concern should the nurse anticipate for the cesarean birth?
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Question 69 of 107
Which of the following comments suggest that a client whose baby was born with a congenital defect is in the bargaining phase of grief?
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Question 70 of 107
The mother notes that her baby has a 'bulge' on the back of one side of the head. She calls the nurse into the room to ask what the bulge is. The nurse notes that the bulge covers the right parietal bone but does not cross the suture lines. The nurse explains to the mother that the bulge results from which of the following?
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Question 71 of 107
A client is receiving IV heparin for deep vein thrombosis. Which of the following medications should the nurse obtain from the pharmacy to have on hand in case of heparin overdose?
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Question 72 of 107
A woman who wishes to breastfeed advises the nurse that she has had breast augmentation surgery. Which of the following responses by the nurse is appropriate?
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Question 73 of 107
A breastfeeding woman has been diagnosed with retained placental fragments 4 days postdelivery. Which of the following breastfeeding complications would the nurse expect to see?
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Question 74 of 107
Which of the following is a priority nursing diagnosis for a woman, G10 P6226, who is PP1 from a spontaneous vaginal delivery with a significant postpartum hemorrhage?
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Question 75 of 107
A client is 3 days post-cesarean delivery for eclampsia. The client is receiving hydralazine (Apresoline) 10 mg 4 times a day by mouth. Which of the following findings would indicate that the medication is effective?
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Question 76 of 107
A woman has just had a low forceps delivery. For which of the following should the nurse assess the woman during the immediate postpartum period?
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Question 77 of 107
A client who received a spinal for her cesarean delivery is complaining of pruritus and has a macular rash on her face and arms. Which of the following medications ordered by the anesthesiologist should the nurse administer at this time?
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Question 78 of 107
A client is postpartum 24 hours from a spontaneous vaginal delivery with rupture of membranes for 42 hours. Which of the following signs/symptoms should the nurse report to the client's health care practitioner?
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Question 79 of 107
What information about pain medication should postpartum discharge instructions include?
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Question 80 of 107
A nurse has administered Methergine (methylergonovine) 0.2 mg po to a grand multipara who delivered vaginally 30 minutes earlier. Which of the following outcomes indicates that the medication is effective?
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Question 81 of 107
A 4-day-old breastfeeding neonate whose birth weight was 2,678 grams has lost 100 grams since the cesarean birth. Which of the following actions should the nurse take?
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Question 82 of 107
A client is being discharged on Coumadin (warfarin) post-pulmonary embolism after a cesarean delivery. Which of the following laboratory values indicates that the medication is effective?
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Question 83 of 107
The nurse is evaluating the effectiveness of an intervention when assisting a woman whose baby has been latched to the nipple only rather than to the nipple and the areola. Which response would indicate that further intervention is needed?
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Question 84 of 107
On admission to the labor and delivery suite, the nurse assesses the discharge needs of a primipara who will be discharged home 4 days after a cesarean delivery. Which of the following questions should the nurse ask the client?
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Question 85 of 107
The nurse is going to assist the mother with the first breastfeeding experience. Which of the following actions should the nurse perform first?
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Question 86 of 107
A nurse who is caring for a mother/newborn dyad on the maternity unit has identified the following nursing diagnosis: Effective breastfeeding. Which of the following would warrant this diagnosis?
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Question 87 of 107
A woman states that all of a sudden her 4-day-old baby is having trouble feeding. On assessment, the nurse notes that the mother's breasts are firm, red, and warm to the touch. The nurse teaches the mother manually to express a small amount of breast milk from each breast. Which observation indicates that the nurse's intervention has been successful?
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Question 88 of 107
A breastfeeding woman, 6 weeks postdelivery, must go into the hospital for a hemorrhoidectomy. Which of the following is the best intervention regarding infant feeding?
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Question 89 of 107
A serum electrolyte report for a client, 1 day post-cesarean delivery for eclampsia, has just been received by the nurse. The client is receiving 5% dextrose in 1/2 normal saline IV at 125 mL/hr and magnesium sulfate 2 G/hr IV via infusion pump. Which of the following values should the nurse report to the surgeon?
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Question 90 of 107
A nurse is assessing a 1-day postpartum client who had a spontaneous vaginal delivery over an intact perineum. The fundus is firm at the umbilicus, lochia moderate, and perineum edematous. One hour after receiving ibuprofen 600 mg po, the client is complaining of perineal pain at level 9 on a 10-point scale. Based on this information, which of the following is an appropriate conclusion for the nurse to make about the client?
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Question 91 of 107
Which anticipatory guidance action by the nurse makes role transition to parenthood easier?
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Question 92 of 107
The nurse should suspect puerperal infection when a client exhibits which of the following?
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Question 93 of 107
A female African American baby has been admitted into the nursery. Which of the following physiological findings would the nurse assess as normal?Select one that doesn't apply
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Question 94 of 107
A nurse is advising a mother of a neonate being discharged from the hospital regarding car seat safety. Which of the following should be included in the teaching plan? Select all that apply.
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Question 95 of 107
The nurse is teaching the parents of a female baby how to change the baby's diapers. Which of the following should be included in the teaching?
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Question 96 of 107
The nurse is assessing a neonate in the newborn nursery. Which of the following findings in a newborn should be reported to the neonatologist?
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Question 97 of 107
The nurse is discussing the neonatal blood screening test with a new mother. The nurse knows that the teaching was successful when the mother states that the test screens for the presence in the newborn of which of the following diseases? Select one that doesn't apply
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Question 98 of 107
An example of binding in during the postpartum period is a
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Question 99 of 107
The nurse assesses the breasts. What is a warning sign?
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Question 100 of 107
The nurse recognizes the postpartum person is in what stage of Rubin’s attachment model when the person is concerned with physical recovery and depends on the nurse or partner for help physically?
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HESI RN · Postpartum Hormonal Changes
Question 101 of 107
A client who is post-cesarean section for severe preeclampsia is receiving magnesium sulfate via IV pump and morphine sulfate via patient-controlled anesthesia (PCA) pump. The nurse enters the room on rounds and notes that the client is not breathing. Which of the following actions should the nurse perform first?
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HESI RN · Postpartum Hormonal Changes
Question 102 of 107
The nurse has completed a postpartum assessment on a patient who delivered 1 hour ago. Which amount of lochia consists of a moderate amount?
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HESI RN · Postpartum Hormonal Changes
Question 103 of 107
What is the term for the separation found in the midline of the abdomen after birth?
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HESI RN · Postpartum Hormonal Changes
Question 104 of 107
Which clinical finding should the nurse suspect if the fundus is palpated on the right side of the abdomen above the expected level?
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HESI RN · Postpartum Hormonal Changes
Question 105 of 107
Four newborns were admitted into the neonatal nursery 1 hour ago. They are all sleeping in overhead warmers. Which of the babies should the nurse ask the neonatologist to evaluate?
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HESI RN · Postpartum Hormonal Changes
Question 106 of 107
The nurse is caring for a birth mother who is relinquishing her newborn. What intervention is appropriate for the nurse?
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HESI RN · Postpartum Hormonal Changes
Question 107 of 107
A client just delivered the placenta pictured below. The nurse will document that the woman delivered which of following placentas?
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