1. Which client care assignment is the most appropriate assignment for a newly graduated licensed practical nurse (LPN)? - ✔✔A 24-year-old
... [Show More] primigravida who delivered a 6-lb, 4-oz (2,835-g) baby vaginally 4 hours ago and is unable to void
2. A client is receiving oxytocin (Pitocin) to treat postpartum hemorrhage. When planning the client's care, the nurse anticipates monitoring for which common adverse reactions? - ✔✔Hypertension and tachycardia
3. Which physiologic response should the nurse expect during the early postpartum period? - ✔✔diuresis
4. (SELECT ALL THAT APPLY) The nurse is instructing the client on breast-feeding. Which instructions should she include to help the mother prevent mastitis? - ✔✔(2) Change the breast pads frequently., (3) Expose your nipples to air part of each day., (4) Wash your hands before handling your breast and breast-feeding., (6) Release the baby's grasp on the nipple before removing him from the breast.
5. The nurse is planning to discharge a 24-year-old gravida 1, para 1, non-English-speaking Hispanic client. The client's English-speaking cousin is acting as a translator for the nurse and client. Which nursing intervention takes priority? - ✔✔Arranging for a home care nurse to assess the client in her home environment
6. When caring for a client who has recently delivered, the nurse assesses the client for urinary retention with overflow. Which of the following descriptions provides an accurate picture of retention with overflow? - ✔✔A varying urge to urinate with an average output of 100 ml
7. After a vaginal delivery, a postpartum client complains of perineal discomfort when sitting. To promote comfort, the nurse should provide which instruction? - ✔✔"Contract your buttocks before sitting or rising."
8. The nurse is discharging a 34-year-old multipara client who, after 16 hours of labor, delivered an 8-lb, 14-oz (4,032-g) baby vaginally. The nurse notes that the mother is rubella-immune with Rh-positive blood. Which client outcome takes priority for this client? - ✔✔The client will verbalize the importance of reporting changes in lochia flow.
9. (SELECT ALL THAT APPLY) The nurse observes several interactions between a mother and her new son. Which of the following behaviors by the mother would the nurse identify as evidence of mother-neonate attachment? - ✔✔(1) Talks and coos to her son, (2) Cuddles her son close to her
10. A client is taking a progestin-only oral contraceptive, or minipill. Progestin use may increase the client's risk of: - ✔✔tubal or ectopic pregnancy.
11. The nurse is preparing to perform a postpartum assessment on a client who gave birth 5 hours ago. Which precaution should the nurse plan to take for this procedure? - ✔✔Washing the hands and wearing gloves
12. While talking to the nurse, the parents of a neonate in the neonatal intensive care unit (NICU) express concern that they're neglecting their 3-year-old son. The nurse suggests a sibling visit. To best promote the sibling's attachment to the neonate, the nurse should: - ✔✔suggest that the sibling bring in a drawing to display near the neonate's crib in the NICU.
13. Which of the following correctly defines puerperium? - ✔✔The 6 weeks following birth
14. The night nurse reports that a postpartum client is homeless, has poor hygiene, and has tested positive for the human immunodeficiency virus (HIV). The nurse assigned to care for the client requests that the assignment be changed because she's pregnant and doesn't want to risk exposure. Which response by the charge nurse indicates an understanding of the ethical responsibilities of a professional nurse? - ✔✔"It's inappropriate to refuse this assignment; all clients should be treated equally."
15. The nurse assesses a client who gave birth 24 hours earlier. Which of the following findings reveals the need for further evaluation? - ✔✔Scant lochia rubra
16. Which of the following options best describes the anticipated actions in the taking-hold phase of the maternal attachment process? - ✔✔Kissing, embracing, and caring for the infant
17. Which of the following interventions would be appropriate to include in the plan of care for a client during the fourth stage of labor? - ✔✔Time with the baby to initiate breast-feeding
18. A new mother who's breast-feeding asks how quickly she can expect to lose the 40 lb she gained during pregnancy. Which response by the nurse is best? - ✔✔"It's important to avoid dieting while your milk supply is being established; a well-balanced diet with gradual weight loss is recommended."
19. The physician prescribes phytonadione (AquaMEPHYTON), 0.5 mg I.M., for a neonate born 30 minutes ago. The nurse has a solution containing 2 mg/ml. How many milliliters of solution should the nurse administer to achieve this dose? - ✔✔0.25
20. Lochia normally progresses in which of the following patterns? - ✔✔Rubra, serosa, alba
21. One day after having a cesarean birth, a client complains of incisional pain that she rates as a 3 on a 1-to-10 scale, with 10 representing the most severe pain. The physician prescribed ibuprofen (Motrin), 400 mg by mouth every 4 to 6 hours, as needed. Which intervention should the nurse take when administering this drug? - ✔✔Administer the drug with meals or milk.
22. Three hours after birth, a client becomes weak and dizzy as she attempts to ambulate for the first time. The client's hemoglobin level at the end of pregnancy was 10.4 g/dl. Two hours later she asks to use the bathroom. Which nursing intervention is the top priority? - ✔✔Obtaining the assistance of a second nurse before attempting to assist the client with ambulation
23. As part of the postpartum follow-up, the nurse calls a new mother at home a few days after discharge. The client answers the telephone, begins to cry, and tells the nurse that she has feelings of inadequacy and isn't coping with the demands of motherhood. Based on this information, which of the following assessments would the nurse make? - ✔✔This is expected behavior for a client 3 to 7 days postpartum.
24. A client is at the end of her 1st postpartum day. When assessing her uterus, the nurse expects to find the top of the fundus at the midline and at which position? - ✔✔One fingerbreadth below the umbilicus
25. A client who gave birth 24 hours ago continues to experience urine retention after several catheterizations. The physician prescribes bethanechol (Urecholine), 10 mg by mouth three times per day. The client asks, "How does bethanechol act on the bladder?" How should the nurse respond? - ✔✔"It stimulates the smooth muscle of the bladder."
26. A client who is breast-feeding her baby experiences pain, redness, and swelling of her left breast 9 days postpartum. She is diagnosed with mastitis. The nurse teaching the client how to care for her infected breast should include which information? - ✔✔Use a warm, moist compress over the painful area.
27. The nurse is teaching a client about oral contraceptive therapy. If a client misses three or more pills in a row, the nurse should instruct her to: - ✔✔discard the pack, use an alternative contraceptive method until her menses begins, and start a new pack on the regular schedule.
28. A clinical pathway is guiding care for a postpartum client who had an uncomplicated vaginal delivery of an 8-lb, 2-oz (3,686-g) baby 24 hours ago. The client has no episiotomy and is bottle-feeding her baby. Which outcome should be achieved within the next 8 hours? - ✔✔Client will demonstrate ability to bottle-feed the neonate.
29. A client who is breast-feeding her infant is experiencing breast engorgement. The nurse suggests breast pumping to relieve the breast engorgement. Which instruction should the nurse provide? - ✔✔Pump each breast for at least 10 minutes every 3 to 4 hours; pump at night only if she's awake.
30. (SELECT ALL THAT APPLY) The nurse is assisting in developing a care plan for a client with an episiotomy. Which interventions would be included for the nursing diagnosis Acute pain related to perineal sutures? - ✔✔(3) Administer sitz baths three to four times per day., (4) Encourage the client to do Kegel exercises. [Show Less]