1. Two days after delivery, a postpartum client prepares for discharge. What should the nurse teach
her about lochia flow?
Incorrect: Lochia does change
... [Show More] color but goes from lochia rubra (bright red) on days 1-3, to lochia
serosa (pinkish brown) on days 4-9, to lochia alba (creamy white) days 10-21.
Incorrect: Numerous clots are abnormal and should be reported to the physician.
Incorrect: Saturation of the perineal pad is considered abnormal and may indicate postpartum
hemorrhage.
The color of the lochia changes from a bright red to white after four days
Numerous large clots are normal for the next three to four days
Saturation of the perineal pad with blood is expected when getting up from the bed
Lochia should last for about 3 weeks, changing color every few days
2. A nurse monitors fetal well-being by means of an external monitor. At the peak of the
contractions, the fetal heart rate has repeatedly dropped 30 beats/min below the baseline. Late
decelerations are suspected and the nurse notifies the physician. Which is the rationale for this
action?
Incorrect: A nuchal cord (cord around the neck) is associated with variable decelerations, not late
decelerations.
Incorrect: Variable decelerations (not late decelerations) are associated with cord compression.
Incorrect: Late decelerations are a result of hypoxia. They are not reflective of the strength of
maternal contractions.
The umbilical cord is wrapped tightly around the fetus' neck
The fetal cord is being compressed due to rapid descent of the fetal head
Maternal contractions are not adequate enough to deliver the fetus
The fetus is not receiving adequate oxygen and is in distress
3. Which preoperative nursing interventions should be included for a client who is scheduled to have
an emergency cesarean birth?
Incorrect: Monitoring O2 saturations and administering pain medications are postoperative
interventions.
Incorrect: Taking vital signs every 15 minutes is a postoperative intervention. Instructing the client
regarding breathing exercises is not appropriate in a crisis situation when the client's anxiety is high,
because information would probably not be retained. In an emergency, there is time only for
essential interventions.
Incorrect: The nurse should have assessed breath sounds upon admission. Breath sounds are
important if the client is to receive general anesthesia, but the anesthesiologist will be listening to
breath sounds in surgery in that case.
Monitor oxygen saturation and administer pain medication.
Assess vital signs every 15 minutes and instruct the client about postoperative care.
Alleviate anxiety and insert an indwelling catheter.
Perform a sterile vaginal examination and assess breath sounds.
4. Which nursing instruction should be given to the breastfeeding mother regarding care of the
breasts after discharge?
Incorrect: Applying lotion to the nipples is not effective for keeping them soft. Excessive amounts of
lotion may harbor microorganisms.
Incorrect: Using soap on the breasts dries the nipples and can cause cracking.
The baby should be given a bottle of formula if engorgement occurs.
The nipples should be covered with lotion when the baby is not nursing.
The breasts should be pumped if the baby is not sucking adequately.
The breasts should be washed with soap and water once per day.
5. A client in preterm labor is admitted to the hospital. Which classification of drugs should the nurse
Incorrect: Anti-infective are used if there is infection. Preterm labor may or may not involve ruptured
membranes with its accompanying risk of infection.
Tocolytics
Anticonvulsants
Glucocorticoids
Anti-infective
6. Which of the following are probable signs, strongly indicating pregnancy?
Incorrect: The presence of fetal heart sounds is a positive sign of pregnancy; quickening is a
presumptive Sign of pregnancy.
Presence of fetal heart sounds and quickening
Missed menstrual periods, nausea, and vomiting
Hegar's sign, Chadwick's sign, and ballottement
Increased urination and tenderness of the breasts
7. Two hours after delivery the nurse assesses the client and documents that the fundus is soft,
boggy, above the level of the umbilicus, and displaced to the right side. The nurse encourages the
client to void. Which is the rationale for this nursing action?
Incorrect: A distended bladder rises out of the abdomen, causing the uterus to be displaced and
increasing the risk of hemorrhage. It does not affect the perineum.
Incorrect: Bladder distention can lead to urinary stasis and infection. This, however, does not relate
to the soft, boggy uterus or the potential for hemorrhage.
Incorrect: Massaging is uncomfortable regardless of whether the bladder is full or not. A full bladder
displaces the uterus causing it not to contract properly, which may lead to postpartum hemorrhage.
A full bladder prevents normal contractions of the uterus.
An overdistended bladder may press against the episiotomy causing dehiscence.
Distention of the bladder can cause urinary stasis and infection.
It makes the client more comfortable when the fundus is massaged.
8. Which site is preferred for giving an IM injection to a newborn?
Incorrect: Newborns do not receive injections in the dorsogluteal site (gluteus maximus) due to
decreased muscle mass.
Ventrogluteal
Rectus femoris
Dorsogluteal
9. During the first twelve hours following a normal vaginal delivery, the client voids 2,000 mL of
urine. How should the nurse interpret this finding?
Incorrect: Urinary tract infections are common during pregnancy and in the postpartum period.
Urinary frequency is a common finding. However, voiding large amounts of urine is not a sign of a
UTI.
Incorrect: High output renal failure occurs with injury/trauma to the kidneys. There has been no
damage to the kidneys. Incorrect: Most women do receive some IV fluids during labor and delivery,
however the IV rates are carefully calculated according to weight.
Urinary tract infection
High output renal failure
Excessive use of IV fluids during delivery
Normal diuresis after delivery
10. If a pregnant client diagnosed with gestational diabetes cannot maintain control of her blood
sugar by diet alone, which medication will she receive?
Incorrect: Glucophage is an oral hypoglycemic. Oral hypoglycemic cross the placenta and can cause
damage to the fetus. They are not used in gestational diabetes for that reason.
Incorrect: Glucagon is a hormone used to raise blood sugar and manage severe hypoglycemia.
Clients with gestational diabetes have hyperglycemia.
Incorrect: DiaBeta is an oral hypoglycemic drug. Oral hypoglycemic agents cross the placenta and
can cause damage to the fetus. They are not used for gestational diabetes for that reason.
Metformin (Glucophage)
Glucagon
Insulin
Glyburide (DiaBeta)
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