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Terms in this set (74)The nurse is caring for a client during the immediate recovery phase or fourth stage of labor. Which action is most important for the nurse to take at this time? Check the uterine fundus and lochia. The postpartum nurse is caring for a mother following delivery of a newborn infant. The nurse performs a perineal assessment on the mother and notes a trickle of bright red blood coming from the perineum. The nurse checks the mother's fundus and notes that it is firm. On review of the mother's record, the nurse also notes that an episiotomy was performed. Which determination should the nurse make based on this information? The bright red bleeding is abnormal and should be reported. The nurse provides instructions to a breastfeeding mother who is experiencing breast engorgement about measures that will provide comfort. Which statement by the mother indicates an understanding of these measures? "I will massage the breasts before feeding to stimulate let-down." Which action, if noted in the new mother, indicates the need for further data collection by the nurse for signs of postpartum depression? The mother constantly complains of tiredness and fatigue. The nurse is reinforcing instructions to the mother following delivery regarding care of the episiotomy site to prevent infection. Which statement by the mother indicates a need for further teaching? I will change the perineum pads three times a day."
A client has had a midline episiotomy. In relation to clients with other types of episiotomies, the nurse anticipates that the client will generally experience which findings? Select all that apply. Less pain The nurse is caring for a client who is being treated with antibiotics for mastitis. To reinforce instructions, what does the nurse tell the client? To complete the entire antibiotic regimen A new mother is seen in the health care clinic 2 weeks after the birth of a healthy newborn. The mother says that she feels as though she has the flu and complains of fatigue and aching muscles. On further data collection the nurse notes a localized area of redness on the left breast, and the mother is diagnosed with mastitis. The mother asks the nurse how the condition occurs. Which nursing response is appropriate? The infection can occur at any time during breastfeeding." A 45-year-old woman delivered her first baby by cesarean section 5 days ago. The postpartum recovery has been complicated by thrombophlebitis in her left leg. She cries frequently and requests to have her newborn infant stay in the nursery. The nurse recognizes that the mother may have intensified "postpartum blues" because of which situation? The client is required to stay on bed rest. The nurse is caring for a client with placenta previa who is at high risk for infection and hemorrhage. The nurse plans care based on which information related to the condition? Fewer muscle fibers in the lower segment of the uterus will result in poor contractions. The nurse who is caring for a postpartum mother being tested for endometritis notes that the client has little interest in caring for her infant. Which intervention should best facilitate the client's participation in infant care? Encouraging the client to take pain medication as prescribed Oxytocin is administered to a client following the delivery of the placenta. The nurse assisting in caring for the client monitors for which effectiveresponse from the medication? Uterine contractions The nurse is monitoring a client at risk for postpartum endometritis. Which observation noted during the first 24 hours after delivery supports this diagnosis? Abdominal tenderness and chills The nurse has a prescription to give a dose of Rho(D) immune globulin to a client who has delivered an infant. Which criteria need to be met in order to administer this medication? Select all that apply. Rh negative mother The nurse is checking the lochia discharge on a 1-day postpartum woman. The nurse notes that the lochia is red and has a foul odor. The nurse determines that this finding indicates which? The presence of infection The nurse is adding to a plan of care for a postpartum client. Which intervention should promote parent-infant bonding Encourage her to hold the infant even when the infant is crying After surgical evacuation and repair of a vaginal hematoma, a 3-day postpartum mother is discharged. The nurse determines that the mother needs further teaching if the new mother makes which statement? The only medications that I will take are prenatal vitamins and stool softeners." The nurse palpates the fundus and checks the character of the lochia of a postpartum client who is in the fourth stage of labor. Which lochia characteristic should the nurse expect to note? Red The nurse is about to reinforce discharge instructions to a postpartum client who delivered a healthy newborn infant. The occurrence of which event should be reported to the primary health care provider? Pain, redness, or swelling in the breasts The nurse in the postpartum unit notes that the result of a rubella titer drawn on a postpartum client during the antepartum period is 1.8. Which should the nurse anticipate to be prescribed by the primary health care provider? Administration of a subcutaneous rubella virus vaccine The nurse is assisting in developing a plan of care for a client preparing to breastfeed. In planning care, which factor is most significant in teaching a client to breastfeed? A positive nurse-client relationship The new breastfeeding mother has been seen in the clinic for the treatment of mastitis. Which comment by the mother indicates a need for further teaching? My left breast is sore, so I will offer only my right breast frequently for breastfeeding." The nurse is monitoring a new mother in the fourth stage of labor for signs of hemorrhage. Which sign noted in the mother indicates an early sign of excessive blood loss and shock? An increase in the pulse rate from 88 to 102 beats per minute Rho(D) immune globulin is prescribed for a client after delivery of a full-term infant. Before administering the medication, the nurse reviews the client's history, recognizing which circumstance as a contraindication for administering this medication? Experiencing a severe reaction to prior administered human globulin The nurse in the newborn nursery is collecting data on a neonate who was born of a mother addicted to cocaine. Which signs/symptoms should the nurse expect to note in the neonate? Select all that apply. Tremors Which nursing actions should decrease the discomfort of an episiotomy? Select all that apply. Performing sitz baths The goal for the postpartum client with deep thrombophlebitis is to prevent the complication of pulmonary embolism. In planning care to assist in meeting this goal, the nurse should perform which action? Administer anticoagulants as prescribed. The nurse is reinforcing instructions to a mother who is bottle-feeding a baby and who is complaining of breast engorgement. Which statement by the client indicates a need for further teaching? I should avoid wearing a bra at this time." A stillborn was delivered in the birthing suite a few hours ago. After the birth, the family has remained together, touching the baby. Which statement by the nurse should further assist the family in their initial period of grief? "Would you like to hold your baby?" A delivery room nurse collects data on a mother who just delivered a healthy newborn infant. The nurse checks the uterus to determine if the placenta has detached. Which findings indicate to the nurse that placental detachment has occurred? Select all that apply. Lengthening of the umbilical cord After delivery the nurse checks the height of the uterine fundus. Which position of the fundus should the nurse expect to note? At the level of the umbilicus The nurse is checking lochia discharge on a client in the immediate postpartum period and notes that the lochia is bright red and contains some small clots. Which interpretation should the nurse make about this finding? The finding is normal. A client experiences subinvolution during the puerperium. The nurse recalls that which factors are the most common causes for this occurrence? Select all that apply. Retained
placental fragments The client received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum, the client's systolic blood pressure (BP) dropped 20 points, the diastolic BP dropped 10 points, and her pulse is 120 beats per minute. The client is very anxious and restless. The nurse is told that the client has a vulvar hematoma. Based on this diagnosis, the nurse should plan which action? Prepare the client for surgery. On the second postpartum day, a woman complains of burning on urination, urgency, and frequency of urination. A urine sample is collected for urinalysis, and the results indicate the presence of a urinary tract infection. The nurse reinforces instructions to the new mother regarding measures to take for the treatment of the infection. Which statement by the mother indicates the need for further teaching? "Foods and fluids that will increase urine alkalinity should be consumed." The nurse is preparing to assist in performing a fundal assessment on a postpartum client. The nurse understands that which is the initialnursing action when performing this assessment? Ask the client to urinate and empty her bladder. The nurse enters a new mother's room and finds that the mother is crying and that the infant is undressed on the bed in front of the mother. The mother looks at the nurse and says, "I can't even dress this baby!" After reassuring the client, which nursing action is the most appropriate? Have the mother place the infant in the bassinet and assist the mother in dressing the baby. A client who is breastfeeding her newborn infant is experiencing nipple soreness. To relieve the soreness, which action should the nurse suggest to the client Begin feeding on the less sore nipple. A postpartum nurse reinforces information provided to a new mother following a vaginal delivery regarding a sitz bath. The nurse determines that the client understands the purpose of the sitz bath when the client makes which statement? A sitz bath will promote healing of the perineum." The nurse provides home care instructions to a postpartum client following a vaginal birth with episiotomy. Which statement by the client indicates the need for further teaching? I can resume sexual activity at any time." The nurse provides explanation to a client prescribed methylergonovine maleate in the immediate postpartum period. Which statement made by the client demonstrates understanding of the rationale for administration? It will help prevent bleeding and control bleeding if it occurs." The parents of a neonate who is not circumcised asks the nurse why the foreskin should not be retracted. The nurse explains that retracting the foreskin should be avoided because which complication may occur? Adhesions The nurse has reinforced instructions to a new mother about how to perform postpartum exercises. The nurse determines that the client understands the instructions when she makes which statement? "I should alternately contract and relax the muscles of the perineal area." The nurse is preparing a list of self-care instructions for a postpartum client who has been diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. Rest during the acute phase. The nurse suspects that the client has a pulmonary embolism when the client exhibits which signs and symptoms? Dyspnea, tachypnea, and tachycardia The nurse is reinforcing instructions to a postpartum cesarean delivery client who is preparing for discharge. Which statement by the client indicates a need for further teaching? I can start doing abdominal exercises as soon as I get home. The nurse is talking to a pregnant client with human immunodeficiency virus (HIV) infection regarding care for the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client? You will need to bottle-feed your newborn." vThe nurse is assisting with caring for a postpartum client who is experiencing uterine hemorrhage. When planning to meet the psychosocial needs of the client, the nurse should plan which action? Keep the client and her family members informed of her progress. The nurse is performing a postpartum fundal assessment on a client 6 hours after delivery. The nurse finds the fundus above the umbilicus and displaced to the right. Which intervention should the nurse do first? Assist the client to the bathroom to void and then reassess the fundus. The nurse is caring for a woman who has delivered a baby after a pregnancy complicated with placenta previa. Which complication is the client most at risk for developing? Postpartum hemorrhage The nurse is adding to a plan of care for a postpartum client. Which intervention should promote parent-infant bonding? Encourage her to hold the infant even when the infant is crying. A postpartum client is at high risk for infection. A goal has been developed that states, "The client will not develop an infection during her hospital stay." Which data support that the goal has been met? Absence of fever A pregnant client tests positive for the hepatitis B virus (HBV), and the client asks the nurse whether she will be able to breastfeed the baby as planned after delivery. The nurse makes which response to the client? Breastfeeding is allowed once the baby has been vaccinated." The nurse is caring for a client who delivered a healthy newborn via vaginal delivery. An episiotomy was performed, and the woman has developed a wound infection at the episiotomy site. The nurse reinforces instructions to the mother regarding care related to the infection. Which statement by the mother indicates the need for further teaching? "I need to isolate my infant for 48 hours after starting the antibiotics A second-day postpartum client diagnosed with a stable cardiac condition has scant lochia with a foul odor and a temperature of 102.2° F. The primary health care provider suspects infection and writes prescriptions to treat the client. Which prescription written by the primary health care provider should the nurse implement first? Obtain culture and sensitivity of lochia and urine. A pregnant client experienced a uterine rupture with subsequent fetal death. After ensuring that the client is physiologically stable, the nurse should take which approach as the first step to support the client psychologically? Collect data regarding how the client perceived the event. The nurse is assisting in developing a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse anticipates that which interventions are included in the plan of care? Select all that apply. Maintaining bed rest The nurse is caring for a client who had a cesarean section to deliver a nonviable fetus as a result of abruptio placentae. The client develops signs of disseminated intravascular coagulopathy (DIC). The spouse asks the nurse what is happening, and the nurse explains the condition. The spouse becomes upset and says to the nurse, "I lost my baby and now my wife! What am I going to do?" Which appropriately describes the situation? The spouse lacks hope because of the loss of the baby and illness of his wife. The nurse is assigned to care for a client in the immediate postpartum period who received epidural anesthesia for delivery, and the nurse monitors the client for complications. Which assessment finding most likely indicates a hematoma? Changes in vital signs The nurse is providing nutritional counseling to a new mother who is breastfeeding her newborn. The nurse instructs the mother to increase her daily caloric intake by which amount? 500 calories per day The nurse is preparing to care for a woman in the immediate postpartum period who has just delivered a healthy newborn. The nurse plans to take the woman's vital signs at which time intervals? Every 15 minutes for the first hour and then every 30 minutes for the next 2 hours The nurse attempts to encourage a new mother to understand and to accept the cesarean section that was necessary to deliver her baby, rather than to focus on the surgical aspect of the procedure. Which nursing statement provides the best encouragement? Tell me about the delivery of your baby." A postpartum client diagnosed with gestational diabetes is scheduled for discharge. During the discharge, the client asks the nurse, "Do I have to worry about this diabetes anymore?" The nurse should make which response to the client? You will be at risk for developing gestational diabetes with your next pregnancy and developing overt diabetes mellitus." In order to prevent mastitis, which discharge instructions should the breastfeeding postpartum client receive from the nurse? Select all that apply. Change breast pads frequently. The nurse is assisting in preparing a plan of care for a client who just delivered a dead fetus. Which initial intervention in meeting the emotional needs of the client and her spouse is appropriate Gather data from the client and spouse about the perception of the event. The nurse in the postpartum unit is assigned to care for a client who delivered a full-term, healthy baby. The nurse receives the report and is told that the mother had lost 500 mL of blood during the delivery. When checking the vital signs, the nurse notes that the woman's pulse is 90 beats per minute and is weak and thready. This finding should indicate which accurate interpretation to the nurse? This may be a sign of hemorrhage or shock. A client is admitted to the labor and delivery suite with an intrauterine fetal demise. The nurse determines that the discussion with the parents was effective in preparing them for the delivery when the parents make which response? Request to hold the infant following delivery When the client has been given instructions about postoperative complications following cesarean delivery, the nurse interprets that the client requires clarification of the information when the client identifies which situation as a reason to notify her primary health care provider? Her temperature is 99° F. A postpartum client suspected of having an infection is informed that she will be unable to have the newborn present in the room with her. The nurse plans care, knowing that which problem is the highest priority at this time? Risk of ineffective bonding between the mother and newborn The nurse is reinforcing instructions to a postpartum cesarean delivery client who is preparing for discharge. Which statement by the client indicates a need for further teaching? I can start doing abdominal exercises as soon as I get home. A mother is breastfeeding her newborn baby and experiences breast engorgement. The nurse should encourage the mother to do which to provide relief of the engorgement? Massage the breasts before feeding to stimulate let-down. The nurse is collecting data on a postpartum client and performs which best intervention when checking for thrombophlebitis in the legs? Checks the calf areas for redness or swelling As a part of discharge teaching, a new mother has been provided with instructions about how to perform postpartum exercises. Which response by the client indicates that the client understands the instructions? She should alternately contract and relax the muscles of the perineal area. Which action, if noted in the new mother, indicates the need for further data collection by the nurse for signs of postpartum depression? The mother constantly complains of tiredness and fatigue. Sets found in the same folderpn NCLEX postpartum81 terms andria_montgomery NCLEX Maternity Antepartum191 terms SKAddis NCLEX Postpartum50 terms Laura_Bailey81 saunders postpartum106 terms seglenda1 Other sets by this creatorExam 1 semester 320 terms Nurse_a_2013 LAB VAULES5 terms Nurse_a_2013 MEDS EXAM 4 GI44 terms Nurse_a_2013 EXAM 4 INSULLIN31 terms Nurse_a_2013 Other Quizlet setsCardiac Adaptive Qs390 terms anatomyman40 Cell Bio Test 3125 terms uche_esther_mgbodile GENERAL BIOLOGY PART II (SUMMER) TEST #227 terms anniegao Anatomy test questions382 terms alfredo_torres37 Related questionsQUESTION where is the oral temp. taken? 8 answers QUESTION What are the 4 types of nursing knowledge? 13 answers QUESTION What is the temp for the bathing water? 13 answers QUESTION In preparing assignments for the shift, which client is best for the charge nurse to assign to a practical nurse? 12 answers What is the immediate postpartum care?The first 24 hours following childbirth (immediate postnatal period), where the majority of morbidity and mortality occurs, is critical for mothers and babies. In Uganda,<50% of women reported receiving such care.
Which interventions are appropriate to promote comfort and healing for a woman during the first 24 hours after a cesarean delivery?For comfort and healing: Apply ice packs in the first 24 hours. Sit in a sitz bath for 20 minutes, three times a day. Take pain medication as recommended by your physician or midwife.
Which interventions are included in the immediate care plan of a postpartum client with a fourth degree laceration quizlet?While assessing a postpartum client, the nurse finds that the client has a fourth-degree laceration. What immediate interventions should the nurse perform while caring for the client? Applying a covered ice pack to the perineum from front to back during the first 24 hours decreases edema and increases comfort.
When examining a postpartum woman the nurse should immediately report?The nurse must report a PPH immediately and prepare for the insertion of a large-bore intravenous catheter, if one is not already present, and the administration of intravenous fluids and oxygen. In the case of an early PPH caused by damage to the birth canal, surgical repair is usually necessary.
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Which action does the nurse implement to enhance client comfort due to an episiotomy immediately after childbirth?
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