sample ques nclex Flashcards
(24 cards)
Which postpartum infection is the most common?
Endometritis
Which situations are common risk factors for developing mastitis?
Select all that apply.
Bottle feeding
Cracked nipples
Wearing an underwire bra
Breast implants
Abrupt weaning of the infant
Cracked nipples
Wearing an underwire bra
Abrupt weaning of the infant
Which task would the nurse teach the postpartum woman to perform to prevent a urinary tract infection (UTI)?
Apply antibiotic ointment to the urethra daily.
Change the perineal pad at each voiding.
Void at least every hour during the postpartum period.
Spray the perineum with a povidine-iodine solution after voiding.
Change the perineal pad at each voiding.
During a home visit, the nurse assesses a woman 2 weeks after a cesarean delivery. Which signs or symptoms would alert the nurse to a possible wound infection?
Select all that apply.
Purulent drainage on the woman’s pants
Well-approximated incision
Oral temperature of 101°F (38.3°C)
Warm incision site
Bruising around the incision site
Purulent drainage on the woman’s pants
Oral temperature of 101°F (38.3°C)
Warm incision site
Which instruction would the nurse provide to a woman who is breastfeeding and has mastitis?
“Limit the amount of time the infant nurses on each breast.”
“Nurse the infant only on the unaffected breast until it resolves.”
“Completely empty each breast at each feeding or use a pump.”
“Wear an underwire bra until the mastitis has subsided.”
“Completely empty each breast at each feeding or use a pump.”
Which signs and symptoms are commonly associated with endometritis?
Select all that apply.
Flank pain
Breast tenderness
Pelvic pain
Excessive lochia
Low-grade fever for 24 hours
Pelvic pain
Excessive lochia
A nurse is reviewing discharge teaching with a patient who has a urinary tract infection (UTI). Which statements by the patient indicate understanding of the teaching?
Select all that apply.
“I will perform perineal care and apply a perineal pad in a back-to-front direction.”
“I will drink cranberry and prune juices to make my urine more acidic.”
“I will drink large amounts of water to flush the bacteria from my urinary tract.”
“I will go back to breastfeeding after I have finished taking the antibiotic.”
“I will take analgesics for any discomfort.”
“I will drink large amounts of water to flush the bacteria from my urinary tract.”
The antepartum nurse is caring for a woman who is 35 weeks’ gestation. The woman reports swelling, tenderness, and redness of the left leg, followed one week later by respiratory symptoms, including coughing and difficulty breathing/panting. Which is the first action the nurse should take?
Notify the health care provider immediately.
The nurse is providing discharge teaching to a woman going home on anticoagulant therapy. Which instructions regarding medication use are appropriate?
remember when the last dose was taken
AND EMPHASIZE LAB TESTING
Which risk factor for DVT is most likely to occur during delivery?
Blood vessel injury
Deep venous thrombosis (DVT)
Can progress to
pulmonary embolism
A woman with deep vein thrombosis (DVT) begins coughing during auscultation of the lungs. what does this indicate
pulmonary embolism
The nurse is performing an initial assessment on a woman receiving anticoagulant therapy. Which assessment finding prompts the nurse to alert the health care provider immediately?
A heart rate of 115 bpm
a characteristic of hypovolemia and could indicate internal bleeding.
A woman with deep vein thrombosis complains of soreness in the affected leg and asks for assistance ambulating. Which response from the nurse is appropriate?
“I will need to look at your leg before you get out of bed.”
The nurse has been assigned to care for several postpartum clients Which of the following clients should the nurse assess first?
1.A multiparous client at 48 hours postpartum who is being discharged.
2.A primiparous client at 2 hours postpartum who gave vaginal birth to a term neonate.
- A multiparous client at 24 hours postpartum whose infant is in the special care nursery.
4.A primiparous client at 48 hours after cesarean birth of a term neonate.
A primiparous client at 2 hours postpartum who gave vaginal birth to a term neonate.
A nurse on the labor-and-birth unit transfers a primiparous client and her term neonate to the mother-baby unit 2 hours after the client gave vaginal birth to the neonate. Which of the following information is a priority for the nurse to report to the nurse receiving the client on the mother-baby unit?
1.Firm fundus when gentle massage is used.
2.Evidence of bonding well with the neonate.
3.Labor that lasted 12 hours with a 1-hour second stage.
4.Temperature of 99°F (37.4°C) and pulse rate of 80 bpm.
1.Firm fundus when gentle massage is used.
A primiparous client develops uterine atony and postpartum hemorrhage 1 hour after a vaginal birth. The physician has prescribed IM prostaglandin-F2a. After administration of the medication, the nurse should observe the client for which of the following?
1.Tachycardia.
2.Hypotension.
3.Constipation.
4.Abdominal distention
Tachycardia.
A multiparous client visits the urgent care center 5 days after a vaginal birth, experiencing persistent lochia rubra in a moderate to heavy amount. The client asks the nurse, “Why am I continuing to bleed like this?” The nurse should instruct the client that this type of postpartum bleeding is usually caused by which of the following?
1.Uterine atony.
2.Cervical lacerations.
3.Vaginal lacerations.
4.Retained placental fragments.
Retained placental fragments.
A multiparous client whose fundus is firm and midline at the umbilicus 8 hours after a vaginal birth tells the nurse that when she ambulated to the bathroom after sleeping for 4 hours, her dark red lochia seemed heavier. Which of the following would the nurse include when explaining to the client about the increased lochia on ambulation?
1.Her bleeding needs to be reported to the physician immediately.
2.The increased lochia occurs from lochia pooling in the vaginal vault.
3.The increase in lochia may be an early sign of postpartum hemorrhage.
4.This increase in lochia usually indicates retained placental fragments”
2.The increased lochia occurs from lochia pooling in the vaginal vault.
A woman who has given birth to a healthy neonate is being discharged. As part of discharge teaching, the nurse should instruct the client to observe vaginal discharge for postpartum hemorrhage and notify the health care provider about:
1.Bleeding that becomes lighter each day
2.Clots the size of golf balls
3.Saturating a pad in an hour
4.Lochia that lasts longer than 1 week
3.Saturating a pad in an hour
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?
- Engorgement.
- Mastitis.
- Blocked milk duct.
- Low milk supply.
- Low milk supply.
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?
- Alteration in comfort related to afterbirth pains.
- Risk for altered parenting related to grand multiparity.
- Fluid volume deficit related to blood loss.
- Risk for sleep deprivation related to mothering role.
- Fluid volume deficit related to blood loss.
A nurse is caring for the following four laboring patients. Which clients should the nurse be prepared to monitor closely for signs of postpartum hemorrhage (PPH)? Select all that apply.
- G1 P0000, delivered a fetal demise at 29 weeks’ gestation.
- G2 P1001, prolonged first stage of labor.
- G2 P0010, delivered by cesarean section for failure to progress.
- G3 P0200, delivered vaginally a 42-week, 2,200-gram neonate.
- G4 P3003, with a succenturiate placenta.
- G2 P1001, prolonged first stage of labor.
- G4 P3003, with a succenturiate placenta.
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?
- Urine output 200 mL for the past 8 hours.
- Weight decrease of 2 pounds since delivery.
- Drop in hematocrit of 2% since admission.
- Pulse rate of 68 beats per minute
- Urine output 200 mL for the past 8 hours.
