1. A 3-day postpartum client, who is not immune to rubella, is to receive the vaccine at discharge. Which of the following must the nurse include in her
... [Show More] discharge teaching regarding the vaccine?
a) The woman should not become pregnant for at least 4 weeks.
b) The woman should pump and dump her breast milk for 1 week.
c) The mother must wear a surgical mask when she cares for the baby.
d) Passive antibodies transported across the placenta will protect the baby. 208 MATERNAL AND NEWBORN SUCCESS
2. A 3-day-postpartum client questions why she is to receive the rubella vaccine before leaving the hospital. Which of the following rationales should guide the nurse’s response?
a) The client’s obstetric status is optimal for receiving the vaccine.
b) The client’s immune system is highly responsive during the postpartum period.
c) The client’s baby will be high risk for acquiring rubella if the woman does not receive the vaccine.
d) The client’s insurance company will pay for the shot if it is given during the immediate postpartum period.
3. A patient, G2P1102, who delivered her baby 8 hours ago, now has a temperature of 100.2ºF. Which of the following is the appropriate nursing intervention at this time?
a) Notify the doctor to get an order for acetaminophen.
b) Request an infectious disease consult from the doctor.
c) Provide the woman with cool compresses.
d) Encourage intake of water and other fluids.
4. To prevent infection, the nurse teaches the postpartum client to perform which of the following tasks?
a) Apply antibiotic ointment to the perineum daily.
b) Change the peripad at each voiding.
c) Void at least every two hours.
d) Spray the perineum with a povidone-iodine solution after toileting.
5. A 3-day-postpartum breastfeeding woman is being assessed. Her breasts are firm and warm to the touch. When asked when she last fed the baby her reply is, “I fed the baby last evening. I let the nurses feed him in the nursery last night. I needed to rest.” Which of the following actions should the nurse take at this time?
a) Encourage the woman exclusively to breastfeed her baby.
b) Have the woman massage her breasts hourly.
c) Obtain an order to culture her expressed breast milk.
d) Take the temperature and pulse rate of the woman.
6. A breastfeeding woman has been counseled on how to prevent engorgement.
Which of the following actions by the mother shows that the teaching was effective?
1. She pumps her breasts after each feeding.
2. She feeds her baby every 2 to 3 hours.
3. She feeds her baby 10 minutes on each side.
4. She supplements each feeding with formula.
7. A 2-day-postpartum breastfeeding woman states, “I am sick of being fat. When can I go on a diet?” Which of the following responses is appropriate?
1. “It is fine for you to start dieting right now as long as you drink plenty of milk.”
2. “Your breast milk will be low in vitamins if you start to diet while breastfeeding.”
3. “You must eat at least 3000 calories per day in order to produce enough milk for your baby.”
4. “Many mothers lose weight when they breastfeed because the baby consumes about 600 calories a day.”
8. A G2P2002, who is postpartum 6 hours from a spontaneous vaginal delivery, is assessed. The nurse notes that the fundus is firm at the umbilicus, there is heavy lochia, and perineal sutures are intact. Which of the following actions should the nurse take at this time?
1. Do nothing. This is a normal finding.
2. Massage the woman’s fundus.
3. Take the woman to the bathroom to void.
4. Notify the woman’s primary health care provider.
9. A client informs the nurse that she intends to bottle-feed her baby. Which of the following actions should the nurse encourage the client to perform?
1. Increase her fluid intake for a few days.
2. Massage her breasts every 4 hours.
3. Apply heat packs to her axillae.
4. Wear a supportive bra 24 hours a day.
10. The nurse in the obstetric clinic received a telephone call from a bottle-feeding mother of a 3-day-old. The client states that her breasts are firm, red, and warm to the touch. Which of the following is the best action for the nurse to advise the client to perform?
1. Intermittently apply ice packs to her axillae and breasts.
2. Apply lanolin to her breasts and nipples every 3 hours.
3. Express milk from the breasts every 3 hours.
4. Ask the primary health care provider to order a milk suppressant.
11. A multigravid, postpartum woman reports severe abdominal cramping whenever she nurses her infant. Which of the following responses by the nurse is appropriate?
1. Suggest that the woman bottle-feed for a few days.
2. Instruct the patient on how to massage her fundus.
3. Instruct the patient to feed using an alternate position.
4. Discuss the action of breastfeeding hormones.
12. The nurse is caring for a breastfeeding mother who asks advice on foods that will provide both vitamin A and iron. Which of the following should the nurse recommend?
1. 1⁄2 cup raw celery dipped in 1 ounce cream cheese.
2. 8 ounce yogurt mixed with 1 medium banana.
3. 12 ounce strawberry milk shake.
4. 11⁄2 cup raw broccoli.
13. A breastfeeding mother states that she has sore nipples. In response to the complaint, the nurse assists with “latch on” and recommends that the mother do which of the following?
1. Use a nipple shield at each breastfeeding.
2. Cleanse the nipples with soap 3 times a day.
3. Rotate infant positions at each feed.
4. Bottle feed for 2 days then resume breastfeeding.
14. Which of the following statements is true about breastfeeding mothers as compared to bottle-feeding mothers?
1. Breastfeeding mothers usually involute completely by 3 weeks postpartum.
2. Breastfeeding mothers have decreased incidence of diabetes mellitus later in life.
3. Breastfeeding mothers show higher levels of bone density after menopause.
4. Breastfeeding mothers are prone to fewer bouts of infection immediately postpartum.
15. A breastfeeding woman, 11⁄2 months post-delivery, calls the nurse in the obstetrician’s office and states, “I am very embarrassed but I need help. Last night I had an orgasm when my husband and I were making love. You should have seen the milk. We were both soaking wet. What is wrong with me?” The nurse should base the response to the client on which of the following?
1. The woman is exhibiting signs of pathological galactorrhea.
2. The same hormone stimulates orgasms and the milk ejection reflex.
3. The woman should have a serum galactosemia assessment done.
4. The baby is stimulating the woman to produce too much milk.
16. A client who is 3 days postpartum asks the nurse, “When may my husband and I begin having sexual relations again?” The nurse should encourage the couple to wait until after which of the following has occurred?
1. The client has had her six-week postpartum check-up.
2. The episiotomy has healed and the lochia has stopped.
3. The lochia has turned to pink and the vagina is no longer tender.
4. The client has had her first postpartum menstrual period.
17. A breastfeeding client, 7 weeks postpartum, complains to an obstetrician’s triage nurse that when she and her husband had intercourse for the first time after the delivery, “I couldn’t stand it. It was so painful. The doctor must have done something terrible to my vagina.” Which of the following responses by the nurse is appropriate?
1. “After a delivery the vagina is always very tender. It should feel better the next time you have intercourse.”
2. “Does your baby have thrush? If so, I bet you have a yeast infection in your vagina.”
3. “Women who breastfeed often have vaginal dryness. A vaginal lubricant may remedy your discomfort.”
4. “Sometimes the stitches of episiotomies heal too tight. Why don’t you come in for an assessment?”
18. The nurse monitors his or her postpartum clients carefully because which of the following physiological changes occurs during the early postpartum period?
1. Decreased urinary output.
2. Increased blood pressure.
3. Decreased blood volume.
4. Increased estrogen level.
19. A woman, 24 hours postpartum, is complaining of profuse diaphoresis. She has no other complaints. Which of the following actions by the nurse is appropriate?
1. Take the woman’s temperature.
2. Advise the woman to decrease her fluid intake.
3. Reassure the woman that this is normal.
4. Inform the neonate’s pediatrician.
20. Which of the following laboratory values would the nurse expect to see in a normal postpartum woman?
1. Hematocrit 39%.
2. White blood cell count 16,000 cells/mm3.
3. Red blood cell count 5 million cells/mm3.
4. Hemoglobin 15 grams/dL.
21. Which of the following client statements indicates a need for additional teaching about selfcare during pregnancy?
■ 1. “I should use nonskid pads when I take a shower or bath.”
■ 2. “I should avoid using soap on my nipples to prevent drying.”
■ 3. “I should sit in a hot tub for 20 minutes to relax after working.”
■ 4. “I should avoid douching even if my vaginal secretions increase.”
22. The nurse is discussing the importance of doing Kegel exercises during the postpartum period. Which of the following should be included in the teaching plan?
1. She should repeatedly contract and relax her rectal and thigh muscles.
2. She should practice by stopping the urine flow midstream every time she voids.
3. She should get on her hands and knees whenever performing the exercises.
4. She should be taught that toned pubococcygeal muscles decrease blood loss.
23. The nurse is evaluating the involution of a woman who is 3 days postpartum. Which of the following findings would the nurse evaluate as normal?
1. Fundus 1 cm above the umbilicus, lochia rosa.
2. Fundus 2 cm above the umbilicus, lochia alba.
3. Fundus 2 cm below the umbilicus, lochia rubra.
4. Fundus 3 cm below the umbilicus, lochia serosa. [Show Less]
