Ch 16 and 22 Flashcards Preview

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Flashcards in Ch 16 and 22 Deck (52):
1

Ch 16
1.
A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a pulse of 60 beats per minute. Which of these actions should the nurse take?
A)
Document the finding, as it is a normal finding at this time.
B)
Contact the physician, as it indicates early DIC.
C)
Contact the physician, as it is a first sign of postpartum eclampsia.
D)
Obtain an order for a CBC, as it suggests postpartum anemia.

Document the finding, as it is a normal finding at this time.

2

2.
To decrease the pain associated with an episiotomy immediately after birth, which action by the nurse would be most appropriate?
A)
Offer warm blankets.
B)
Encourage the woman to void.
C)
Apply an ice pack to the site.
D)
Offer a warm sitz bath.

Apply an ice pack to the site.

3

3.
A postpartum client has a fourth-degree perineal laceration. The nurse would expect which of the following medications to be ordered?
A)
Ferrous sulfate (Feosol)
B)
Methylergonovine (Methergine)
C)
Docusate (Colace)
D)
Bromocriptine (Parlodel)

Docusate (Colace)

4

4.
Which statement would alert the nurse to the potential for impaired bonding between mother and newborn?
A)
ìYou have your daddy's eyes.î
B)
ìHe looks like a frog to me.î
C)
ìWhere did you get all that hair?î
D)
ìHe seems to sleep a lot.î

He looks like a frog to me

5

5.
After a normal labor and birth, a client is discharged from the hospital 12 hours later. When the community health nurse makes a home visit 2 days later, which finding would alert the nurse to the need for further intervention?
A)
Presence of lochia serosa
B)
Frequent scant voidings
C)
Fundus firm, below umbilicus
D)
Milk filling in both breasts

Frequent scant voidings

6

6.
A primipara client who is bottle feeding her baby begins to experience breast engorgement on her third postpartum day. Which instruction would be most appropriate to aid in relieving her discomfort?
A)
ìExpress some milk from your breasts every so often to relieve the distention.î
B)
ìRemove your bra to relieve the pressure on your sensitive nipples and breasts.î
C)
ìApply ice packs to your breasts to reduce the amount of milk being produced.î
D)
ìTake several warm showers daily to stimulate the milk let-down reflex.î

Apply ice packs to your breasts to reduce the amount of milk being produced

7

7.
The nurse administers RhoGAM to an Rh-negative client after delivery of an Rh-positive newborn based on the understanding that this drug will prevent her from:
A)
Becoming Rh positive
B)
Developing Rh sensitivity
C)
Developing AB antigens in her blood
D)
Becoming pregnant with an Rh-positive fetus

Developing Rh sensitivity

8

8.
Which of the following factors in a client's history would alert the nurse to an increased risk for postpartum hemorrhage?
A)
Multiparity, age of mother, operative delivery
B)
Size of placenta, small baby, operative delivery
C)
Uterine atony, placenta previa, operative procedures
D)
Prematurity, infection, length of labor

Uterine atony, placenta previa, operative procedures

9

9.
After teaching parents about their newborn, the nurse determines that the teaching was successful when they identify the development of a close emotional attraction to a newborn by parents during the first 30 to 60 minutes after birth as which of the following?
A)
Reciprocity
B)
Engrossment
C)
Bonding
D)
Attachment

Bonding

10

10.
A nurse is working as part of a committee to establish policies to promote bonding and attachment. Which practice would be least effective in achieving this goal?
A)
Allowing unlimited visiting hours on maternity units
B)
Offering round-the-clock nursery care for all infants
C)
Promoting rooming-in
D)
Encouraging infant contact immediately after birth

Offering round-the-clock nursery care for all infants

11

11.
When developing the plan of care for the parents of a newborn, the nurse identifies interventions to promote bonding and attachment based on the rationale that bonding and attachment are most supported by which measure?
A)
Early parentñinfant contact following birth
B)
Expert medical care for the labor and birth
C)
Good nutrition and prenatal care during pregnancy
D)
Grandparent involvement in infant care after birth

Early parentñinfant contact following birth

12

12.
A postpartum woman is having difficulty voiding for the first time after giving birth. Which of the following would be least effective in helping to stimulate voiding?
A)
Pouring warm water over her perineal area
B)
Having her hear the sound of water running nearby
C)
Placing her hand in a basin of cool water
D)
Standing her in the shower with the warm water on

Placing her hand in a basin of cool water

13

13.
The nurse is assisting a postpartum woman out of bed to the bathroom for a sitz bath. Which of the following would be a priority?
A)
Placing the call light within her reach
B)
Teaching her how the sitz bath works
C)
Telling her to use the sitz bath for 30 minutes
D)
Cleaning the perineum with the peri-bottle

Placing the call light within her reach

14

14.
A nurse is reviewing the medical record of a postpartum client. The nurse identifies that the woman is at risk for a postpartum infection based on which of the following? (Select all that apply.)
A)
History of diabetes
B)
Labor of 12 hours
C)
Rupture of membranes for 16 hours
D)
Hemoglobin level 10 mg/dL
E)
Placenta requiring manual extraction

History of diabetes
Hemoglobin level 10 mg/dL
Placenta requiring manual extraction

15

15.
A nurse is completing a postpartum assessment. Which finding would alert the nurse to a potential problem?
A)
Lochia rubra with a fleshy odor
B)
Respiratory rate of 16 breaths per minute
C)
Temperature of 101∞ F
D)
Pain rating of 2 on a scale from 0 to 10

Temperature of 101∞ F

16

16.
The nurse is assessing a postpartum client's lochia and finds that there is about a 4-inch stain on the perineal pad. The nurse documents this finding as which of the following?
A)
Scant
B)
Light
C)
Moderate
D)
Large

Light

17

17.
When reviewing the medical record of a postpartum client, the nurse notes that the client has experienced a third-degree laceration. The nurse understands that the laceration extends to which of the following?
A)
Superficial structures above the muscle
B)
Through the perineal muscles
C)
Through the anal sphincter muscle
D)
Through the anterior rectal wall

Through the anal sphincter muscle

18

18.
A nurse is observing a postpartum client interacting with her newborn and notes that the mother is engaging with the newborn in the en face position. Which of the following would the nurse be observing?
A)
Mother placing the newborn next to bare breast.
B)
Mother making eye-to-eye contact with the newborn
C)
Mother gently stroking the newborn's face
D)
Mother holding the newborn upright at the shoulder

Mother making eye-to-eye contact with the newborn

19

19.
After teaching a group of students about risk factors associated with postpartum hemorrhage, the instructor determines that the teaching was successful when the students identify which of the following as a risk factor? (Select all that apply.)
A)
Prolonged labor
B)
Placenta previa
C)
Null parity
D)
Hydramnios
E)
Labor augmentation

Placenta previa
Hydramnios
Labor augmentation

20

20.
A postpartum woman who is breast-feeding tells the nurse that she is experiencing nipple pain. Which of the following would be least appropriate for the nurse to suggest?
A)
Use of a mild analgesic about 1 hour before breast-feeding
B)
Application of expressed breast milk to the nipples
C)
Application of glycerin-based gel to the nipples
D)
Reinstruction about proper latching-on technique

Use of a mild analgesic about 1 hour before breast-feeding

21

21.
A nurse is developing a teaching plan for a postpartum woman who is breast-feeding about sexuality and contraception. Which of the following would the nurse most likely include? (Select all that apply.)
A)
Resumption of sexual intercourse about two weeks after delivery
B)
Possible experience of fluctuations in sexual interest
C)
Use of a water-based lubricant to ease vaginal discomfort
D)
Use of combined hormonal contraceptives for the first three weeks
E)
Possibility of increased breast sensitivity during sexual activity

Possible experience of fluctuations in sexual interest
Use of a water-based lubricant to ease vaginal discomfort
Possibility of increased breast sensitivity during sexual activity

22

22.
After teaching a postpartum woman about breast-feeding, the nurse determines that the teaching was successful when the woman states which of the following?
A)
ìI should notice a decrease in abdominal cramping during breast-feeding.î
B)
ìI should wash my hands before starting to breast-feed.î
C)
ìThe baby can be awake or sleepy when I start to feed him.î
D)
ìThe baby's mouth will open up once I put him to my breast.î

I should wash my hands before starting to breast-feed.

23

23.
A postpartum woman who is bottle-feeding her newborn asks the nurse, ìAbout how much should my newborn drink at each feeding?î The nurse responds by saying that to feel satisfied, the newborn needs which amount at each feeding?
A)
1 to 2 ounces
B)
2 to 4 ounces
C)
4 to 6 ounces
D)
6 to 8 ounces

2 to 4 ounces

24

24.
A nurse is observing a postpartum woman and her partner interact with the their newborn. The nurse determines that the parents are developing parental attachment with their newborn when they demonstrate which of the following? (Select all that apply.)
A)
Frequently ask for the newborn to be taken from the room
B)
Identify common features between themselves and the newborn
C)
Refer to the newborn as having a monkey-face
D)
Make direct eye contact with the newborn
E)
Refrain from checking out the newborn's features

Identify common features between themselves and the newborn
Make direct eye contact with the newborn

25

25.
After reviewing information about postpartum blues, a group of students demonstrate understanding when they state which of the following about this condition?
A)
ìPostpartum blues is a long-term emotional disturbance.î
B)
ìSleep usually helps to resolve the blues.î
C)
ìThe mother loses contact with reality.î
D)
ìExtended psychotherapy is needed for treatment.î

Sleep usually helps to resolve the blues.

26

Ch 22
1.
Review of a primiparous woman's labor and birth record reveals a prolonged second stage of labor and extended time in the stirrups. Based on an interpretation of these findings, the nurse would be especially alert for which of the following?
A)
Retained placental fragments
B)
Hypertension
C)
Thrombophlebitis
D)
Uterine subinvolution

Thrombophlebitis

27

2.
As part of an inservice program, a nurse is describing a transient, self-limiting mood disorder that affects mothers after childbirth. The nurse correctly identifies this as postpartum:
A)
Depression
B)
Psychosis
C)
Bipolar disorder
D)
Blues

Blues

28

3.
A woman who is 2 weeks postpartum calls the clinic and says, ìMy left breast hurts.î After further assessment on the phone, the nurse suspects the woman has mastitis. In addition to pain, the nurse would assess for which of the following?
A)
An inverted nipple on the affected breast
B)
No breast milk in the affected breast
C)
An ecchymotic area on the affected breast
D)
Hardening of an area in the affected breast

Hardening of an area in the affected breast

29

4.
A group of students are reviewing the causes of postpartum hemorrhage. The students demonstrate understanding of the information when they identify which of the following as the most common cause?
A)
Labor augmentation
B)
Uterine atony
C)
Cervical or vaginal lacerations
D)
Uterine inversion

Uterine atony

30

5.
After presenting a class on measures to prevent postpartum hemorrhage, the presenter determines that the teaching was successful when the class states which of the following as an important measure to prevent postpartum hemorrhage due to retained placental fragments?
A)
Administering broad-spectrum antibiotics
B)
Inspecting the placenta after delivery for intactness
C)
Manually removing the placenta at delivery
D)
Applying pressure to the umbilical cord to remove the placenta

Inspecting the placenta after delivery for intactness

31

6.
A multipara client develops thrombophlebitis after delivery. Which of the following would alert the nurse to the need for immediate intervention?
A)
Dyspnea, diaphoresis, hypotension, and chest pain
B)
Dyspnea, bradycardia, hypertension, and confusion
C)
Weakness, anorexia, change in level of consciousness, and coma
D)
Pallor, tachycardia, seizures, and jaundice

Dyspnea, diaphoresis, hypotension, and chest pain

32

7.
A client experienced prolonged labor with prolonged premature rupture of membranes. The nurse would be alert for which of the following in the mother and the newborn?
A)
Infection
B)
Hemorrhage
C)
Trauma
D)
Hypovolemia

Infection

33

8.
When assessing the postpartum woman, the nurse uses indicators other than pulse rate and blood pressure for postpartum hemorrhage based on the knowledge that:
A)
These measurements may not change until after the blood loss is large
B)
The body's compensatory mechanisms activate and prevent any changes
C)
They relate more to change in condition than to the amount of blood lost
D)
Maternal anxiety adversely affects these vital signs

These measurements may not change until after the blood loss is large

34

9.
The nurse is assessing a woman with abruption placentae who has just given birth. The nurse would be alert for which of the following?
A)
Severe uterine pain
B)
Board-like abdomen
C)
Appearance of petechiae
D)
Inversion of the uterus

Appearance of petechiae

35

10.
A nurse is assessing a postpartum woman. Which finding would cause the nurse to be most concerned?
A)
Leg pain on ambulation with mild ankle edema
B)
Calf pain with dorsiflexion of the foot.
C)
Perineal pain with swelling along the episiotomy
D)
Sharp stabbing chest pain with shortness of breath

Sharp stabbing chest pain with shortness of breath

36

11.
A woman experiencing postpartum hemorrhage is ordered to receive a uterotonic agent. Which of the following would the nurse least expect to administer?
A)
Oxytocin
B)
Methylergonovine
C)
Carboprost
D)
Terbutaline

Terbutaline

37

12.
Which of the following would be most appropriate when massaging a woman's fundus?
A)
Place the hands on the sides of the abdomen to grasp the uterus.
B)
Use an up-and-down motion to massage the uterus.
C)
Wait until the uterus is firm to express clots.
D)
Continue massaging the uterus for at least 5 minutes.

Wait until the uterus is firm to express clots.

38

13.
After teaching a woman with a postpartum infection about care after discharge, which client statement indicates the need for additional teaching?
A)
ìI need to call my doctor if my temperature goes above 100.4∞ F.î
B)
ìWhen I put on a new pad, I'll start at the back and go forward.î
C)
ìIf I have chills or my discharge has a strange odor, I'll call my doctor.î
D)
ìI'll point the spray of the peribottle so the water flows front to back.î

When I put on a new pad, I'll start at the back and go forward

39

14.
A nurse suspects that a postpartum client is experiencing postpartum psychosis. Which of the following would most likely lead the nurse to suspect this condition?
A)
Delirium
B)
Feelings of anxiety
C)
Sadness
D)
Insomnia

Delirium

40

15.
A postpartum woman is diagnosed with metritis. The nurse interprets this as an infection involving which of the following? (Select all that apply.)
A)
Endometrium
B)
Decidua
C)
Myometrium
D)
Broad ligament
E)
Ovaries
F)
Fallopian tubes

Endometrium
Decidua
Myometrium

41

16.
A group of nursing students are reviewing information about mastitis and its causes. The students demonstrate understanding of the information when they identify which of the following as the most common cause?
A)
E. coli
B)
S. aureus
C)
Proteus
D)
Klebsiella

S. aureus

42

17.
A home health care nurse is assessing a postpartum woman who was discharged 2 days ago. The woman tells the nurse that she has a low-grade fever and feels ìlousy.î Which of the following findings would lead the nurse to suspect metritis? (Select all that apply.)
A)
Lower abdominal tenderness
B)
Urgency
C)
Flank pain
D)
Breast tenderness
E)
Anorexia

Lower abdominal tenderness
Anorexia

43

18.
A postpartum client comes to the clinic for her routine 6-week visit. The nurse assesses the client and suspects that she is experiencing subinvolution based on which of the following?
A)
Nonpalpable fundus
B)
Moderate lochia serosa
C)
Bruising on arms and legs
D)
Fever

Moderate lochia serosa

44

19.
Assessment of a postpartum client reveals a firm uterus with bright-red bleeding and a localized bluish bulging area just under the skin at the perineum. The woman also is complaining of significant pelvic pain and is experiencing problems with voiding. The nurse suspects which of the following?
A)
Hematoma
B)
Laceration
C)
Bladder distention
D)
Uterine atony

Hematoma

45

20.
A postpartum woman is ordered to receive oxytocin to stimulate the uterus to contract. Which of the following would be most important for the nurse to do?
A)
Administer the drug as an IV bolus injection.
B)
Give as a vaginal or rectal suppository.
C)
Piggyback the IV infusion into a primary line.
D)
Withhold the drug if the woman is hypertensive.

Piggyback the IV infusion into a primary line.

46

21.
Assessment of a postpartum woman experiencing postpartum hemorrhage reveals mild shock. Which of the following would the nurse expect to assess? (Select all that apply.)
A)
Diaphoresis
B)
Tachycardia
C)
Oliguria
D)
Cool extremities
E)
Confusion

Diaphoresis
Cool extremities

47

22.
A group of students are reviewing risk factors associated with postpartum hemorrhage. The students demonstrate understanding of the information when they identify which of the following as associated with uterine tone? (Select all that apply.)
A)
Rapid labor
B)
Retained blood clots
C)
Hydramnios
D)
Operative birth
E)
Fetal malpostion

Rapid labor
Hydramnios

48

23.
A nurse is massaging a postpartum client's fundus and places the nondominant hand on the area above the symphysis pubis based on the understanding that this action:
A)
Determines that the procedure is effective
B)
Helps support the lower uterine segment
C)
Aids in expressing accumulated clots
D)
Prevents uterine muscle fatigue

Helps support the lower uterine segment

49

24.
A nurse is developing a plan of care for a woman who is at risk for thromboembolism. Which of the following would the nurse include as the most cost-effective method for prevention?
A)
Prophylactic heparin administration
B)
Compression stocking
C)
Early ambulation
D)
Warm compresses

Early ambulation

50

25.
A postpartum woman who developed deep vein thrombosis is being discharged on anticoagulant therapy. After teaching the woman about this treatment, the nurse determines that additional teaching is needed when the woman states which of the following?
A)
ìI will use a soft toothbrush to brush my teeth.î
B)
ìI can take ibuprofen if I have any pain.î
C)
ìI need to avoid drinking any alcohol.î
D)
ìI will call my health care provider if my stools are black and tarry.î

I can take ibuprofen if I have any pain

51

26.
The nurse is developing a discharge teaching plan for a postpartum woman who has developed a postpartum infection. Which of the following would the nurse most likely include in this teaching plan? (Select all that apply.)
A)
Taking the prescribed antibiotic until it is finished
B)
Checking temperature once a week
C)
Washing hands before and after perineal care
D)
Handling perineal pads by the edges
E)
Directing peribottle to flow from back to front

Taking the prescribed antibiotic until it is finished
Washing hands before and after perineal care
Handling perineal pads by the edges

52

27.
A nurse is assessing a postpartum client who is at home. Which statement by the client would lead the nurse to suspect that the client may be developing postpartum depression?
A)
ìI just feel so overwhelmed and tired.î
B)
ìI'm feeling so guilty and worthless lately.î
C)
ìIt's strange, one minute I'm happy, the next I'm sad.î
D)
ìI keep hearing voices telling me to take my baby to the river.î

I'm feeling so guilty and worthless lately