Saunders NCLEX Postpartum Questions Exam Questions & Answers, With Rationales-A rubella titer result of a 1-day postpartum client is less than 1:8, and a
... [Show More] rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply.
1.
Breast-feeding needs to be stopped for 3 months.
2.
Pregnancy needs to be avoided for 1 to 3 months.
3.
The vaccine is administered by the subcutaneous route.
4.
Exposure to immunosuppressed individuals needs to be avoided.
5.
A hypersensitivity reaction can occur if the client has an allergy to eggs.
6.
The area of the injection needs to be covered with a sterile gauze for 1 week. - 2, 3, 4, 5
Rubella vaccine is administered to women who have not had rubella or women who are not serologically immune. The vaccine may be administered in the immediate postpartum period to prevent the possibility of contracting rubella in future pregnancies. The live attenuated rubella virus is not communicable in breast milk; breast-feeding does not need to be stopped. The client is counseled not to become pregnant for 1 to 3 months after immunization as specified by the health care provider because of a possible risk to a fetus from the live virus vaccine; the client must be using effective birth control at the time of the immunization. The client should avoid contact with immunosuppressed individuals because of their low immunity toward live viruses and because the virus is shed in the urine and other body fluids. The vaccine is administered by the subcutaneous route. A hypersensitivity reaction can occur if the client has an allergy to eggs because the vaccine is made from duck eggs. There is no useful or necessary reason for covering the area of the injection with a sterile gauze.
The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client?
1.
"You will need to bottle-feed your newborn."
2.
"You will need to feed your newborn by nasogastric tube feeding."
3.
"You will be able to breast-feed for 6 months and then will need to switch to bottle-feeding."
4.
"You will be able to breast-feed for 9 months and then will need to switch to bottle-feeding." - 1
Perinatal transmission of human immunodeficiency virus (HIV) can occur during the antepartum period, during labor and birth, or in the postpartum period if the mother is breast-feeding. Clients who have HIV are advised not to breast-feed. There is no physiological reason why the newborn needs to be fed by nasogastric tube.
A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would further assist the family in their initial period of grief?
1.
"What can I do for you?"
2.
"Now you have an angel in heaven."
3.
"Don't worry, there is nothing you could have done to prevent this from happening."
4.
"We will see to it that you have an early discharge so that you don't have to be reminded of this experience." - 1
When a loss or death occurs, the nurse should ensure that parents have been honestly told about the situation by their health care provider or others on the health care team. It is important for the nurse to be with the parents at this time and to use therapeutic communication techniques. The nurse must also consider cultural and religious practices and beliefs. The correct option provides a supportive, giving, and caring response. Options 2, 3, and 4 are blocks to communication and devalue the parents' feelings.
The nurse in a maternity unit is providing emotional support to a client and her husband who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process?
1.
"We want to attend a support group."
2.
"We never want to try to have a baby again."
3.
"We are going to try to adopt a child immediately."
4.
"We are okay, and we are going to try to have another baby immediately." - 1
A support group can help the parents work through their pain by nonjudgmental sharing of feelings. The correct option identifies a statement that would indicate positive, normal grieving. Although the other options may indicate reactions of the client and significant other, they are not specifically a part of the normal grieving process.
The nurse evaluates the ability of a hepatitis B-positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn?
1.
The mother requests that the window be closed before feeding.
2.
The mother holds the newborn properly during feeding and burping.
3.
The mother tests the temperature of the formula before initiating feeding.
4.
The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding. - 4
Hepatitis B virus is highly contagious and is transmitted by direct contact with blood and body fluids of infected persons. The rationale for identifying childbearing clients with this disease is to provide adequate protection of the fetus and the newborn, to minimize transmission to other individuals, and to reduce maternal complications. The correct option provides the best evaluation of maternal understanding of disease transmission. Option 1 will not affect disease transmission. Options 2 and 3 are appropriate feeding techniques for bottle-feeding, but do not minimize disease transmission for hepatitis B.
The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction?
1.
"I will begin abdominal exercises immediately."
2.
"I will notify the health care provider if I develop a fever."
3.
"I will turn on my side and push up with my arms to get out of bed."
4.
"I will lift nothing heavier than my newborn baby for at least 2 weeks." - 1
A cesarean delivery requires an incision made through the abdominal wall and into the uterus. Abdominal exercises should not start immediately after abdominal surgery; the client should wait at least 3 to 4 weeks postoperatively to allow for healing of the incision. Options 2, 3, and 4 are appropriate instructions for the client after a cesarean delivery.
After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn infant briefly with her fingertips. What should the nurse do to help the woman process the delivery?
1.
Encourage the mother to breast-feed soon after birth.
2.
Support the mother in her reaction to the newborn infant.
3.
Tell the mother that it is important to hold the newborn infant.
4.
Document a complete account of the mother's reaction on the birth record. - 2
Precipitous labor is labor that lasts 3 hours or less. Women who have experienced precipitous labor often describe feelings of disbelief that their labor progressed so rapidly. To assist the client to process what has happened, the best option is to support the client in her reaction to the newborn infant. Options 1, 3, and 4 do not acknowledge the client's feelings.
The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with a placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa?
1.
Infection
2.
Hemorrhage
3.
Chronic hypertension
4.
Disseminated intravascular coagulation - 2
In placenta previa, the placenta is implanted in the lower uterine segment. The lower uterine segment does not contain the same intertwining musculature as the fundus of the uterus, and this site is more prone to bleeding. Options 1, 3, and 4 are not risks that are related specifically to placenta previa.
The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2° F. What is the priority nursing action?
1.
Document the findings.
2.
Retake the temperature in 15 minutes.
3.
Notify the health care provider (HCP).
4.
Increase hydration by encouraging oral fluids. - 4
The client's temperature should be taken every 4 hours while she is awake. Temperatures up to 100.4° F (38° C) in the first 24 hours after birth often are related to the dehydrating effects of labor. The appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. Although the nurse also would document the findings, the appropriate action would be to increase hydration. Taking the temperature in another 15 minutes is an unnecessary action. Contacting the HCP is not necessary.
The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action would be most appropriate?
1.
Raise the head of the client's bed.
2.
Obtain hemoglobin and hematocrit levels.
3.
Instruct the client to request help when getting out of bed.
4.
Inform the nursery room nurse to avoid bringing the newborn to the client until the mother's symptoms have subsided. - 3
Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that caution the nurse to focus interventions on the client's safety. The nurse should advise the client to get help the first few times she gets out of bed. Option 1 is not a helpful action in this situation and would not relieve the symptoms. Option 2 requires a health care provider's prescription. Option 4 is unnecessary.
The postpartum nurse is providing instructions to a client after delivery of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function?
1.
3 days postpartum
2.
7 days postpartum
3.
On the day of delivery
4.
Within 2 weeks postpartum - 1
After birth, the nurse should auscultate the client's abdomen in all four quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days postpartum. Surgery, anesthesia, and the use of opioids and pain control agents also contribute to the longer period of altered bowel functions. Options 2, 3, and 4 are incorrect.
The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client had a midline episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client?
1.
Client pain level
2.
Inadequate urinary output
3.
Client perception of body changes
4.
Potential for imbalanced body fluid volume - 1
The priority nursing consideration for a client who delivered 2 hours ago and who has a midline episiotomy and hemorrhoids is client pain level. Most clients have some degree of discomfort during the immediate postpartum period. There are no data in the question that indicate inadequate urinary output, the presence of client perception of body changes, and potential for imbalanced body fluid volume.
The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all that apply.
1.
"I should wear a bra that provides support."
2.
"Drinking alcohol can affect my milk supply."
3.
"The use of caffeine can decrease my milk supply."
4.
"I will start my estrogen birth control pills again as soon as I get home."
5.
"I know if my breasts get engorged I will limit my breast-feeding and supplement the baby."
6.
"I plan on having bottled water available in the refrigerator so I can get additional fluids easily." - 1, 2, 3, 6
The postpartum client should wear a bra that is well-fitted and supportive. Breasts may leak between feedings or during coitus, and the client is taught to place a breast pad in the bra. Breast-feeding clients should increase their daily fluid intake; having bottled water available indicates that the postpartum client understands the importance of increasing fluids. If engorgement occurs, the client should not limit breast-feeding, but should breast-feed frequently. Oral contraceptives containing estrogen are not recommended for breast-feeding mothers. Common causes of decreased milk supply include formula use; inadequate rest or diet; smoking by the mother or others in the home; and use of caffeine, alcohol, or other medications.
The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include?
1.
The diet should include additional fluids.
2.
Prenatal vitamins should be discontinued.
3.
Soap should be used to cleanse the breasts.
4.
Birth control measures are unnecessary while breast-feeding. - 1
The diet for a breast-feeding client should include additional fluids. Prenatal vitamins should be taken as prescribed, and soap should not be used on the breasts because it tends to remove natural oils, which increases the chance of cracked nipples. Breast-feeding is not a method of contraceptio
A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention would be most appropriate?
1.
Elevate the client's legs.
2.
Massage the fundus until it is firm.
3.
Ask the client to turn on her left side.
4.
Push on the uterus to assist in expressing clots. - 2
If the uterus is not contracted firmly, the initial intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage. Elevating the client's legs and positioning the client on the side would not assist in managing uterine atony.
The nurse is caring for four 1-day postpartum clients. Which client would require further nursing action?
1.
The client with mild afterpains
2.
The client with a pulse rate of 60 beats/minute
3.
The client with colostrum discharge from both breasts
4.
The client with lochia that is red and has a foul-smelling odor - 4
Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor or an odor similar to menstrual flow. Foul-smelling or purulent lochia usually indicates infection, and these findings are not normal. The other options are normal findings for a 1-day postpartum client.
When performing a postpartum assessment on a client, a nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate?
1.
Document the findings.
2.
Reassess the client in 2 hours.
3.
Notify the health care provider.
4.
Encourage increased oral intake of fluids. - 3
Normally, a few small clots may be noted in the lochia in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the appropriate action is to notify the HCP. Reassessing the client in 2 hours would delay necessary treatment. Increasing oral intake of fluids would not be a helpful action in this situation. [Show Less]