The Nurse is Caring For a Client Who Had An Emergency Cesarean Section

1. The nurse is caring for a client who had an emergency cesarean section, with her husband in attendance the day before. The baby’s Apgar was 9/9. The woman and her partner had attended childbirth education classes and had anticipated having a water birth with family present. Which of the following comments by the nurse is appropriate? a) “Sometimes babies just don’t deliver the way we expect them to.” b) “With all of your preparations, it must have been disappointing for you to have had a cesarean.” c) “I know you had to have surgery, but you are very lucky that your baby was born healthy.” d) “At least your husband was able to be with you when the baby was born.” 2. A nurse has brought a 2-hour-old baby to a mother from the nursery. The nurse is going to assist the mother with the first breastfeeding experience. Which of the following actions should the nurse perform first? a) b) c) d) Compare mother’s and baby’s identification bracelets. Help the mother into a comfortable position. Teach the mother about a proper breast latch. Tickle the baby’s lips with the mother’s nipple. 3. The obstetrician has ordered that a post-op cesarean section client’s patient-controlled analgesia (PCA) be discontinued. Which of the following actions by the nurse is appropriate? a) Discard the remaining medication in the presence of another nurse. b) Recommend waiting until her pain level is zero to discontinue the medicine. c) Discontinue the medication only after the analgesia is completely absorbed. d) Return the unused portion of medication to the narcotics cabinet. 4. A client is receiving an epidural infusion of a narcotic for pain relief after a cesarean section. The nurse would report to the anesthesiologist if which of the following were assessed? a) b) c) d) Respiratory rate 8 rpm. Complaint of thirst. Urinary output of 250 cc/hr. Numbness of feet and ankles. 5. A client, 2 days postoperative from a cesarean section, complains to the nurse that she has yet to have a bowel movement since the surgery. Which of the following responses by the nurse would be appropriate at this time? a) “That is very concerning. I will request that your physician order an enema for you.” b) “Two days is not that bad. Some patients go four days or longer without a movement.” c) “You have been taking antibiotics through your intravenous. That is probably why you are constipated.” d) “Fluids and exercise often help to combat constipation. Take a stroll around the unit and drink lots of fluid.” 6. A post–cesarean section, breastfeeding client, whose subjective pain level is 2/5, requests her as needed (prn) narcotic analgesics every 3 hours. She states, “I have decided to make sure that I feel as little pain from this experience as possible.” Which of the following should the nurse conclude in relation to this woman’s behavior? a) The woman needs a stronger narcotic order. b) The woman is high risk for severe constipation. c) The woman’s breast milk volume may drop while taking the medicine. d) The woman’s newborn may become addicted to the medication. 7. A nurse is assessing a 1-day postpartum woman who had her baby by cesarean section. Which of the following should the nurse report to the surgeon? a) b) c) d) Fundus at the umbilicus. Nodular breasts. Pulse rate 60 bpm. Pad saturation every 30 minutes. 8. The nurse is assessing the midline episiotomy on a postpartum client. Which of the following findings should the nurse expect to see? a) Moderate serosanguinous drainage. b) Well-approximated edges. c) Ecchymotic area distal to the episiotomy. d) An area of redness adjacent to the incision. 9. A client, G1P1, who had an epidural, has just delivered a daughter, Apgar 9/9, over a mediolateral episiotomy. The physician used low forceps. While recovering, the client states, “I’m a failure. I couldn’t stand the pain and couldn’t even push my baby out by myself!” Which of the following is the best response for the nurse to make? a) “You’ll feel better later after you have had a chance to rest and to eat.” b) “Don’t say that. There are many women who would be ecstatic to have that baby.” c) “I am sure that you will have another baby. I bet that it will be a natural delivery.” d) “To have things work out differently than you had planned is disappointing.” 10. The nurse is developing a standard care plan for postpartum clients who have had midline episiotomies. Which of the following interventions should be included in the plan? a) Assist with stitch removal on third postpartum day. b) Administer analgesics every four hours per doctor orders. c) Teach client to contract her buttocks before sitting. d) Irrigate incision twice daily with antibiotic solution. 11. A client, G1P1001, 1-hour postpartum from a spontaneous vaginal delivery with local anesthesia, states that she needs to urinate. Which of the following actions by the nurse is appropriate at this time? a) Provide the woman with a bedpan. b) Advise the woman that the feeling is likely related to the trauma of delivery. c) Remind the woman that she still has a catheter in place from the delivery. d) Assist the woman to the bathroom. 12. A nurse is assessing the fundus of a client during the immediate postpartum period. Which of the following actions indicates that the nurse is performing the skill correctly? a) The nurse measures the fundal height using a paper centimeter tape. b) The nurse stabilizes the base of the uterus with his or her dependent hand. c) The nurse palpates the fundus with the tips of his or her fingers. d) The nurse precedes the assessment with a sterile vaginal exam. 13. A 1-day postpartum woman states, “I think I have a urinary tract infection. I have to go to the bathroom all the time.” Which of the following actions should the nurse take? a) Assure the woman that frequent urination is normal after delivery. b) Obtain an order for a urine culture. c) Assess the urine for cloudiness. d) Ask the woman if she is prone to urinary tract infections. 14. The nurse is assessing the laboratory report on a 2-day postpartum G1P1001. The woman had a normal postpartum assessment this morning. Which of the following results should the nurse report to the primary health care provider? a. White blood cells—12,500 cells/mm3. b. Red blood cells—4,500,000 cells/mm3. c. Hematocrit—26%. d. Hemoglobin—11 g/dL 15. A bottle-feeding woman, 11⁄2 weeks postpartum from a vaginal delivery, calls the obstetric office to state that she has saturated 2 pads in the past 1 hour. Which of the following responses by the nurse is appropriate? a) “You must be doing too much. Lie down for a few hours and call back if the bleeding has not subsided.” b) “You are probably getting your period back. You will bleed like that for a day or two and then it will lighten up.” c) “It is not unusual to bleed heavily every once in a while, after a baby is born. It should subside shortly.” d) “It is important for you to be examined by the doctor today. Let me check to see when you can come in.” 16. A client, 2 days postpartum from a spontaneous vaginal delivery, asks the nurse about postpartum exercises. Which of the following responses by the nurse is appropriate? a) “You must wait to begin to perform exercises until after your six-week postpartum checkup.” b) “You may begin Kegel exercises today, but do not do any other exercises until the doctor tells you that it is safe.” c) “By next week you will be able to return to the exercise schedule you had during your prepregnancy.” d) “You can do some Kegel exercises today and then slowly increase your toning exercises over the next few weeks.” 17. The nurse is examining a 2-day postpartum client whose fundus is 2 cm below the umbilicus and whose bright red lochia saturates about 4 inches of a pad in 1 hour. What should the nurse document in the nursing record? a) b) c) d) Abnormal involution, lochia rubra heavy. Abnormal involution, lochia serosa scant. Normal involution, lochia rubra moderate. Normal involution, lochia serosa heavy. 18. The nurse palpates a distended bladder on a woman who delivered vaginally 2 hours earlier. The woman refuses to go to the bathroom, “I really don’t need to go.” Which of the following responses by the nurse is appropriate? a) b) c) d) “Okay. I must be palpating your uterus.” “I understand but I still would like you to try to urinate.” “You still must be numb from the local anesthesia.” “That is a problem. I will have to catheterize you.” 19. A client, G1P0101, postpartum 1 day, is assessed. The nurse notes that the client’s lochia rubra is moderate and her fundus is boggy 2 cm above the umbilicus and deviated to the right. Which of the following actions should the nurse take first? a) b) c) d) Notify the woman’s primary health care provider. Massage the woman’s fundus. Escort the woman to the bathroom to urinate. Check the quantity of lochia on the peripad. 20. The nurse has taught a new admission to the postpartum unit about pericare. Which of the following indicates that the client understands the procedure? a) b) c) d) The woman performs the procedure twice a day. The woman sits in warm tap water for ten minutes. The woman sprays her perineum from front to back. The woman mixes tap water with hydrogen peroxide. 21. The nurse informs a postpartum woman that ibuprofen (Advil) is especially effective for afterbirth pains. What is the scientific rationale for this? a) b) c) d) Ibuprofen is taken every two hours. Ibuprofen has an antiprostaglandin effect. Ibuprofen is given via the parenteral route. Ibuprofen is administered in high doses. 22. It is 4 p.m. A client, G1P0000, 3 cm dilated, asks the nurse when the dinner tray will be served. The nurse replies a) “Laboring clients are never allowed to eat.” b) “Believe me, you will not want to eat by the time it is the dinner hour. Most women throw up, you know.” c) “The dinner tray should arrive in an hour or two.” d) “A heavy meal is discouraged. I can get clear fluids for you whenever you would like them, though.” 23. A physician has ordered an iron supplement for a postpartum woman. The nurse strongly suggests that the woman take the medicine with which of the following drinks? a) b) c) d) Skim milk. Ginger ale. Orange juice. Chamomile tea. 24.On admission to the labor and delivery unit, a client’s hemoglobin (Hgb) was assessed at 11.0 gm/dL, and her hematocrit (Hct) at 33%. Which of the following values would the nurse expect to see 2 days after a normal spontaneous vaginal delivery? a) b) c) d) Hgb 12.5 gm/dL; Hct 37%. Hgb 11.0 gm/dL; Hct 33%. Hgb 10.5 gm/dL; Hct 31%. Hgb 9.0 gm/dL; Hct 27%. 25. During a postpartum assessment, it is noted that a G1P1001 woman, who delivered vaginally over an intact perineum, has a cluster of hemorrhoids. Which of the following would be appropriate for the nurse to include in the woman’s health teaching? Select all that apply. a) The client should use a sitz bath daily as a relief measure. b) The client should digitally replace external hemorrhoids into her rectum. c) The client should breastfeed frequently to stimulate oxytocin to reduce the size of the hemorrhoids. d) The client should be advised that the hemorrhoids will increase in size and quantity with subsequent pregnancies. e) The client should apply topical anesthetic as a relief measure. 26. Which of the following is the priority nursing action during the immediate postpartum period? a) Palpate fundus. b) Check pain level. c) Perform pericare. d) Assess breasts. 27. Immediately after delivery, a woman is shaking uncontrollably. Which of the following nursing actions is most appropriate? a. b. c. d. Provide the woman with warm blankets. Put the woman in Trendelenburg position. Notify the primary health care provider. Increase the intravenous infusion. 28. One nursing diagnosis that a nurse has identified for a postpartum client is: Risk for intrauterine infection r/t vaginal delivery. During the postpartum period, which of the following goals should the nurse include in the care plan in relation to this diagnosis? Select all that apply. a) b) c) d) e) The client will drink sufficient quantities of fluid. The client will have a stable white blood cell count. The client will have a normal temperature. The client will have normal-smelling vaginal discharge. The client will take two or three sitz baths each day. 29. Which of the following nursing interventions would be appropriate for the nurse to perform in order to achieve the client care goal: The client will not develop postpartum thrombophlebitis? a) b) c) d) Encourage early ambulation. Promote oral fluid intake. Massage the legs of the client twice daily. Provide the client with high fiber foods. 30. The nurse is developing a plan of care for the postpartum client during the “taking in” phase. Which of the following should the nurse include in the plan? a) b) c) d) Teach baby care skills like diapering. Discuss the labor and birth with the mother. Discuss contraceptive choices with the mother. Teach breastfeeding skills like pumping. 31. The nurse is developing a plan of care for the postpartum client during the “taking hold” phase. Which of the following should the nurse include in the plan? a) b) c) d) Provide the client with a nutritious meal. Encourage the client to take a nap. Assist the client with activities of daily living. Assure the client that she is an excellent mother. 32. Which finding would the nurse view as normal when evaluating the laboratory reports of a 34-week gestation client? a) Anemia. b) Thrombocytopenia. c) Polycythemia. d) Hyperbilirubinemia. 33. The nurse asks a 31-week gestation client to lie on the examining table during a prenatal examination. In which of the following positions should the client be placed? a) b) c) d) Orthopneic. Lateral-recumbent. Sims’. Semi-Fowler’s. 34. A third-trimester client is being seen for routine prenatal care. Which of the following assessments will the nurse perform during the visit? Select all that apply. a) b) c) d) e) Blood glucose. Blood pressure. Fetal heart rate. Urine protein. Pelvic ultrasound. 35. A nurse is working in the prenatal clinic. Which of the following findings seen in third-trimester pregnant women would the nurse consider to be within normal limits? Select all that apply. a) b) c) d) e) Leg cramps. Varicose veins. Hemorrhoids. Fainting spells. Lordosis. 36. A 36-week gestation gravid lies flat on her back. Which of the following maternal signs/symptoms would the nurse expect to observe? a) b) c) d) Hypertension. Dizziness. Rales. Chloasma. 37. The nurse is interviewing a 38-week gestation Muslim woman. Which of the following questions would be inappropriate for the nurse to ask? a) b) c) d) “Do you plan to breastfeed your baby?” “What do you plan to name the baby?” “Which pediatrician do you plan to use?” “How do you feel about having an episiotomy?” 38. A woman is 36-weeks’ gestation. Which of the following tests will be done during her prenatal visit? a) b) c) d) Glucose challenge test. Amniotic fluid volume assessment. Vaginal and rectal cultures. Karyotype analysis. 39. A 34-week gestation woman calls the obstetric office stating, “Since last night I have had three nosebleeds.” Which of the following responses by the nurse is appropriate? a) “You should see the doctor to make sure you are not becoming severely anemic.” b) “Do you have a temperature?” c) “One of the hormones of pregnancy makes the nasal passages prone to bleeds.” d) “Do you use any inhaled drugs?” 40. The nurse asks a woman about how the woman’s husband is dealing with the pregnancy. The nurse concludes that counseling is needed when the woman makes which of the following statements? a) “My husband is ready for the pregnancy to end so that we can have sex again.” b) “My husband has gained quite a bit of weight during this pregnancy.” c) “My husband seems more worried about our finances now than before the pregnancy.” d) “My husband plays his favorite music for my belly so the baby will learn to like it.” 41. A man has inherited the gene for familial adenomatous polyposis (FAP), an autosomal dominant disease. He and his wife wish to have a baby. Which of the following would provide the couple with the highest probability of conceiving a healthy child? a) b) c) d) Amniocentesis. Chorionic villus sampling. Pre-implantation genetic diagnosis. Gamete intrafallopian transfer. 42. A woman asks the obstetrician’s nurse about cord blood banking. Which of the following responses by the nurse would be best? a) “I think it would be best to ask the doctor to tell you about that.” b) “The cord blood is frozen in case your baby develops a serious illness in the future.” c) “The doctors could transfuse anyone who gets into a bad accident with the blood.” d) “Cord blood banking is very expensive and the blood is rarely ever used.” 43. A 3-month-old baby has been diagnosed with cystic fibrosis. The mother states, “How could this happen? I had an amniocentesis during my pregnancy and everything was supposed to be normal!” What does the nurse understand about this situation? a) Cystic fibrosis cannot be diagnosed by amniocentesis. b) The baby may have an uncommon genetic variant of the disease. c) It is possible that the laboratory technician made an error. d) Instead of obtaining fetal cells the doctor probably harvested maternal cells. 44. The nurse discusses the results of a 3-generation pedigree with the proband who has breast cancer. Which of the following information must the nurse consider? a) The proband should have a complete genetic analysis done. b) The proband is the first member of the family to be diagnosed. c) The proband’s first degree relatives should be included in the discussion. d) The proband’s sisters will likely develop breast cancer during their lives. 45. The nurse is analyzing the pedigree shown below. How should the nurse interpret the genotype of the individual in location II-4? a) b) c) d) Affected male. Unaffected female. Stillborn child. Child of unknown sex. 46. The nurse is analyzing the pedigree shown below. How should the nurse interpret the genotype of the individuals in locations IV-9 and IV-10? a) b) c) d) Fraternal twins. Unaffected couple. Proband and sister. Known heterozygotes. 47. A woman who is a carrier for sickle cell anemia is advised that if her baby has two recessive genes, the penetrance of the disease is 100%, but the expressivity is variable. Which of the following explanations will clarify this communication for the mother? All babies with 2 recessive sickle cell genes will: a) Develop painful vaso-occlusive crises during their first year of life. b) Exhibit at least some signs of the disease while in the neonatal nursery. c) Show some symptoms of the disease but the severity of the symptoms will be individual. d) Be diagnosed with sickle cell trait but will be healthy and disease-free throughout their lives. 48. Analyze the pedigree below. Which of the following inheritance patterns does the pedigree depict? a) b) c) d) Autosomal recessive. Mitochondrial inheritance. X-linked recessive. Y-linked trait. 49. A client, in her third trimester, is concerned that she will not know the difference between labor contractions and normal aches and pains of pregnancy. How should the nurse respond? a) “Don’t worry. You’ll know the difference when the contractions start.” b) “The contractions may feel just like a backache, but they will come and go.” c) “Contractions are a lot worse than your pregnancy aches and pains.” d) “I understand. You don’t want to come to the hospital before you are in labor.” 50. The nurse is counseling a pregnant couple who are both carriers for phenylketonuria (PKU), an autosomal recessive disease. Which of the following comments by the nurse is appropriate? a) “I wish I could give you good news, but because this is your first pregnancy, your child will definitely have PKU.” b) “Congratulations, you must feel relieved that the odds of having a sick child are so small.” c) “There is a 2 out of 4 chance that your child will be a carrier like both of you.” d) “There is a 2 out of 4 chance that your child will have PKU.” 51. To obtain the obstetric conjugate measurement, the nurse would do which of the following? a) b) c) d) Add 1.5 cm to the transverse diameter. First measure the angle of the pubic arch. Subtract 1.5 to 2 cm from the diagonal conjugate. Measure the diameter of the pelvic inlet. 40 The Nursing Care of the Childbearing Family The Pregnant Client in Childbirth Preparation Classes 52. The nurse is developing a teaching plan for a client entering the third trimester of her pregnancy. The nurse should include which of the following in the plan? Select all that apply. a) b) c) d) e) f) Differentiating the fetus from the self. Ambivalence concerning pregnancy. Experimenting with mothering roles. Realignment of roles and tasks. Trying various caregiver roles. Concern about labor and delivery. 53. A new antenatal G 6, P 4, Ab 1 client attends her fi rst prenatal visit with her husband. The nurse is assessing this couple’s psychological response to their pregnancy. Which of the following requires the most immediate follow up? a) The couple are concerned with fi nancial changes this pregnancy causes. b) The couple expresses ambivalence about the current pregnancy. c) The father of the baby states that the pregnancy has changed the mother’s focus. d) The father of the baby is irritated that the mother is not like she was before pregnancy. 54. When preparing a t endocrine changes that normally occur during pregnancy, the nurse should include information about which of the following subjects? a) Human placental lactogen maintains the corpus luteum. b) Progesterone is responsible for hyperpigmentation and vascular skin changes. c) Estrogen relaxes smooth muscle in the respiratory tract. d) The thyroid enlarges with an increase in basal metabolic rate. 55. When developing a series of parent classes on fetal development, which of the following should the nurse include as being developed by the end of the third month (9 to 12 weeks)? a) b) c) d) External genitalia. Myelinization of nerves. Brown fat stores. Air ducts and alveoli. 56. A primigravid client attending parenthood classes tells the nurse that there is a history of twins in her family. What should the nurse tell the client? a) Monozygotic twins result from fertilization of two ova by different sperm. b) Monozygotic twins occur by chance regardless of race or heredity. c) Dizygotic twins are usually of the same sex. d) Dizygotic twins occur more often in primigravid than in multigravid clients. 57. During a 2-hour childbirth preparation class focusing on the labor and delivery process for primigravid clients, the nurse is describing the maneuvers that the fetus goes through during the labor process when the head is the presenting part. In which order do these maneuvers occur? a) b) c) d) Engagement Descent Flexion Internal rotation 58. A primigravid client in a Preparation for Parenting class asks how much blood is lost during an uncomplicated delivery. The nurse should tell the woman: a) “The maximum blood loss considered within normal limits is 500 mL.” b) “The minimum blood loss considered within normal limits is 1,000 mL.” c) “Blood loss during a delivery is rarely estimated unless there is a hemorrhage.” d) “It would be very unusual if you lost more than 100 mL of blood during the delivery.” 59. Which of the following statements by a primigravid client about the amniotic fluid and sac indicates the need for further teaching? a) “The amniotic fluid helps to dilate the cervix once labor begins.” b) “Fetal nutrients are provided by the amniotic fluid.” c) “Amniotic fluid provides a cushion against impact of the maternal abdomen.” d) “The fetus is kept at a stable temperature by the amniotic fl uid and sac.” 60. During a childbirth preparation class, a primigravid client at 36 weeks’ gestation tells the nurse, “My lower back has really been bothering me lately.” Which of the following exercises suggested by the nurse would be most helpful? a) b) c) d) Pelvic rocking. Deep breathing. Tailor sitting. Squatting. Antepartal Care 41 61. A client is experiencing pain during the fi rst stage of labor. What should the nurse instruct the client to do to manage her pain? Select all that apply. a) b) c) d) e) Walk in the hospital room. Use slow chest breathing. Request pain medication on a regular basis. Lightly massage her abdomen. Sip ice water. 62. During a Preparation for Parenting class, one of the participants asks the nurse, “How will I know if I am really in labor?” The nurse should tell the participant which of the following about true labor contractions? ■ 1. “Walking around helps to decrease true contractions.” ■ 2. “True labor contractions may disappear with ambulation, rest, or sleep.” ■ 3. “The duration and frequency of true labor contractions remain the same.” ■ 4. “True labor contractions are felt fi rst in the lower back, then the abdomen.” 63. After instructing participants in a childbirth education class about methods for coping with discomforts in the first stage of labor, the nurse determines that one of the pregnant clients needs further instruction when she says that she has been practicing which of the following? b) Increased risk for urinary tract infections. c) Increased peripheral vascular resistance. d) Increased hemoglobin levels. 66. The nurse is obtaining information to support the need for improved prenatal care services in the community. Which of the following information is most important to include? ■ 1. The maternal mortality rate. ■ 2. The infant mortality rate. ■ 3. The perinatal mortality rate. ■ 4. The neonatal mortality rate. ■ 1. Biofeedback. The Pregnant Client with Risk Factors ■ 2. Effleurage. 67. A multigravid client at 32 weeks’ gestation has exprienced hemolytic disease of the newborn in a previous pregnancy. The nurse should prepare the client for frequent antibody titer evaluations obtained from which of the following? ■ 3. Guided imagery. ■ 4. Pelvic tilt exercises. 64. After a Preparation for Parenting class session, a pregnant client tells the nurse that she has had some yellow-gray frothy vaginal discharge and local itching. The nurse’s best action is to advise the client to do which of the following? ■ 1. Placental blood. ■ 1. Use an over-the-counter cream for yeast infections. ■ 4. Maternal blood. ■ 2. Schedule an appointment at the clinic for an examination. 68. A client with a past medical history of ventricular septal defect repaired in infancy is seen at the prel clinic. She is complainingnata of dyspnea with exertion and being very tired. Her vital signs are 98, 80, 20, BP 116/72. She has + 2 pedal edema and clear breath sounds. As the nurse plans this client’s care, which of the following is her cardiac classification according to the New York Heart Association Cardiac Disease classification? ■ 3. Administer a vinegar douche under low pressure. ■ 4. Prepare for preterm labor and delivery. 65. The topic of physiologic changes that occur during pregnancy is to be included in a parenting class for primigravid clients who are in their fi rst half of pregnancy. Which of the following would be important for the nurse to include in the teaching plan? a) Decreased plasma volume. ■ 2. Amniotic fl uid. ■ 3. Fetal blood. ■ 1. Class I. ■ 2. Class II. ■ 3. Class III. 1. Assists the woman into a squatting position. ■ 4. Class IV. 2. Advises the woman to push only when she feels the urge. 69. A primigravid client has completed her fi rst prenatal visit and blood work. Her laboratory test for the hepatitis B surface antigen (HBsAg) is positive. The nurse can advise the client that the plan of care for this newborn will include? Select all that apply. 3. Encourages the woman to push slowly and steadily. ■ 1. Hepatitis B immune globulin at birth. ■ 2. Series of three hepatitis B vaccinations per recommended schedule. ■ 3. Hepatitis B screening when born. ■ 4. Isolation of infant during hospitalization. ■ 5. Universal precautions for mother and infant. ■ 6. Contraindication for breast-feeding because the mother is HBsAg positive. 70. A woman who has had asthma since she was a child and it is under control when the client takes her medication correctly and consistently is now pregnant for the fi rst time. Which of the following client statements concerning asthma during pregnancy indicates the need for further instruction? 4. Massages the perineum with mineral oil. 72. The nurse is performing a vaginal examination on a client in labor. The client is found to be 5 cm dilated, 90% effaced, and station 2. Which of the following has the nurse palpated? 1. Thin cervix. 2. Bulging fetal membranes. 3. Head at the pelvic outlet. 4. Closed cervix. 73. A couple has delivered a 28-week fetal demise. Which of the following nursing actions are appropriate to take? Select all that apply. 1. Swaddle the baby in a baby blanket. 2. Discuss funeral options for the baby. 3. Encourage the couple to try to get pregnant again soon. 4. Ask the couple whether or not they would like to hold the baby. ■ 1. “I need to continue taking my asthma medication as prescribed.” 5. Advise the couple that the baby’s death was probably for the best. ■ 2. “It is my goal to prevent or limit asthma attacks.” 74. A client is being discharged on Coumadin (warfarin) post– pulmonary embolism after a cesarean delivery. Which of the following should be included in the patient teaching? ■ 3. “During an asthma attack, oxygen needs continue to be high for mother and fetus.” ■ 4. “Bronchodilators should be used only when necessary because of the risk they present to the fetus.” 1. Only take ibuprofen for pain. 71. To decrease the possibility of a perineal laceration during delivery, the nurse performs which of the following interventions prior to the delivery? 3. Drink grapefruit juice daily. 2. Avoid eating dark green leafy vegetables. 4. Report any decrease in urinary output. 376 MATERNAL AND NEWBORN SUCCESS 2. “Do you have any allergies?” 75. A client just delivered the placenta pictured below. For which of the following complications should the nurse carefully observe the woman? 3. “Do you scar easily?” 4. “Are there many stairs in your home?” 2. Postpartum hemorrhage. 79. A woman is receiving Paxil (paroxetine) for postpartum depression. In order to prevent a drug/food interaction, the client must be advised to refrain from consuming which of the following? 3. Prolapsed uterus. 1. Alcohol. 4. Vaginal hematoma. 2. Grapefruit. 76. Which of the following is a priority nursing diagnosis for a woman, G10P6226, who is PP1 from a spontaneous vaginal delivery with a significant postpartum hemorrhage? 3. Milk. 1. Endometrial ischemia. 1. Alteration is comfort related to afterbirth pains. 2. Risk for altered parenting related to grand multiparity. 3. Fluid volume deficit related to blood loss. 4. Risk for sleep deprivation related to mothering role. 77. A woman has just had a macrosomic baby after a 12-hour labor. For which of the following complications should the woman be carefully monitored? 1. Uterine atony. 2. Hypoprolactinemia. 3. Infection. 4. Mastitis. 78. On admission to the labor and delivery suite, the nurse assesses the discharge needs of a primipara who will be discharged home 4 days after a cesarean delivery. Which of the following questions should the nurse ask the client? 1. “Have you ever had anesthesia before?” 4. Cabbage. 80. A nurse is assessing a 1 day-postpartum client who had a spontaneous vaginal delivery over an intact perineum. The fundus is firm at the umbilicus, lochia moderate, and perineum edematous. One hour after receiving ibuprofen 600 mg po, the client is complaining of perineal pain at level 9 on a 10 point scale. Based on this information, which of the following is an appropriate conclusion for the nurse to make about the client? 1. She should be assessed by her doctor. 2. She should have a sitz bath. 3. She may have a hidden laceration. 4. She needs a narcotic analgesic. 81. A breastfeeding mother calls the obstetrician’s office with a complaint of pain in one breast. Upon inspection, a diagnosis of mastitis is made. Which of the following nursing interventions is appropriate? 1. Advise the woman to apply ice packs to her breasts. 2. Encourage the woman to breastfeed frequently. 3. Inform the woman that she should wean immediately. 4. Direct the woman to notify her pediatrician as soon as possible. 82. A woman, who wishes to breastfeed, advises the nurse that she has had breast augmentation surgery. Which of the following responses by the nurse is appropriate? 1. Breast implants often contaminate the milk with toxins. 85. A woman, 26 weeks’ gestation, has just delivered a fetal demise. Which of the following nursing actions is appropriate at this time? 1. Remind the mother that she will be able to have another baby in the future. 2. Dress the baby in a tee shirt and swaddle the baby in a receiving blanket. 2. The glandular tissue of women who need implants is often deficient. 3. Ask the woman if she would like the doctor to prescribe a sedative for her. 3. Babies often have difficulty latching to the nipples of women with breast implants. 4. Remove the baby from the delivery room as soon as possible. 4. Women who have implants are often able exclusively to breastfeed. 83. A breastfeeding client calls her obstetrician stating that her baby was diagnosed with thrush and that her breasts have become infected as well. Which of the following organisms has caused the baby’s and mother’s infection? 1. Staphylococcus aureus. 2. Streptococcus pneumonia. 3. Escherichia coli. 4. Candida albicans. 84. A client is on magnesium sulfate via IV pump for severe preeclampsia. Other than patellar reflex assessments, which of the following noninvasive assessments should the nurse perform to monitor the client for early signs of magnesium sulfate toxicity? 1. Serial grip strengths. 2. Kernig assessments. 3. Pupillary responses. 4. Apical heart rate checks. 86. A client, G1P0000, is PP1 from a normal spontaneous delivery of a baby boy, Apgar 5/6. Because the client exhibited addictive behaviors, a toxicology assessment was performed; the results were positive for alcohol and cocaine. Which of the following interventions is appropriate for this postpartum client? 1. Strongly advise the client to breastfeed her baby. 2. Perform hourly incentive spirometer respiratory assessments. 3. Suggest that the nursery nurse feed the baby in the nursery. 4. Provide the client with supervised instruction on baby care skills. 87. A client is 10 minutes postpartum from a forceps delivery of a 4500-gram Down syndrome neonate over a right mediolateral episiotomy. The client is at risk for each of the following nursing diagnoses. Which of the diagnoses is highest priority at this time? 1. Ineffective breastfeeding. 2. Fluid volume deficit. 3. Infection. 4. Pain. 88. A client is postpartum 24 hours from a spontaneous vaginal delivery with rupture of membranes for 42 hours. Which of the following signs/symptoms should the nurse report to the client’s health care practitioner? 1. Foul-smelling lochia. 2. Engorged breasts. 3. Cracked nipples. 4. Cluster of hemorrhoids. 89. A client is 36 hours post–cesarean section. Which of the following assessments would indicate that the client may have a paralytic ileus? 92. A nurse has administered Methergine (methylergonovine) 0.2 mg po to a grand multipara who delivered vaginally 30 minutes earlier. Which of the following outcomes indicates that the medication is effective? 1. Blood pressure 120/80. 2. Pulse rate 80 bpm and regular. 3. Fundus firm at umbilicus. 4. Increase in prothrombin time. 3. Omphalocele. 93. A nurse on the postpartum unit is caring for two postoperative cesarean clients. One client had spinal anesthesia for the delivery while the other client had an epidural. Which of the following complications will the nurse monitor the spinal client for that the epidural client is much less high risk for? 4. Absent bowel sounds. 1. Pruritus. 1. Abdominal striae. 2. Oliguria. 90. 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? 2. Nausea. 3. Postural headache. 1. Urine output 200 mL for last 8 hours. 4. Respiratory depression. 2. Weight decrease of 2 pounds since delivery. 3. Drop in hematocrit of 2% since admission. 94. A postpartum woman has been diagnosed with postpartum psychosis. Which of the following signs/symptoms would the client exhibit? 4. Pulse rate of 68 beats per minute. 1. Hallucinations. 91. A nurse is working on the postpartum unit. Which of the following patients should the nurse assess first? 2. Polyphagia. 1. PP1 from vaginal delivery complains of burning on urination. 2. PP1 from forceps delivery with blood loss of 500 mL at time of delivery. 3. PP3 from vacuum delivery with hemoglobin of 7.2 g/dL. 4. PO3 from cesarean delivery complains of firm and painful breasts. 3. Induced vomiting. 4. Weepy sadness. 95. The nurse is providing discharge counseling to a woman who is breastfeeding her baby. What should the nurse advise the woman to do if she should palpate tender, hard nodules in her breasts? 1. Gently massage the areas toward the nipple especially during feedings. is negative. Which of the following actions by the nurse is appropriate? 2. Apply ice to the areas between feedings. 1. Advise the client to keep her physician appointment at the end of the week in order to receive her RhoGAM injection. 3. Bottlefeed for the next twenty-four hours. 4. Apply lanolin ointment to the areas after each and every breastfeeding. 96. A woman states that all of a sudden her 4-day-old baby is having trouble feeding. On assessment, the nurse notes that the mother’s breasts are firm, red, and warm to the touch. The nurse teaches the mother manually to express a small amount of breast milk from each breast. Which observation indicates that the nurse’s intervention has been successful? 2. Carefully check the record to make sure that the RhoGAM injection was administered. 3. Notify the client that because her baby’s Coombs’ test was negative she will not receive an injection of RhoGAM. 4. Inform the client’s physician that because the woman is being discharged on the second day, the RhoGAM could not be given. 1. The mother’s nipples are soft to the touch. 99. The nurse is caring for a couple who are in the labor/delivery room immediately after the delivery of a dead baby with visible defects. Which of the following actions by the nurse is appropriate? 2. The baby swallows after every 5th suck. 1. Discourage the parents from naming the baby. 3. The baby’s pre- and postfeed weight change is 20 milliliters. 2. Advise the parents that the baby’s defects would be too upsetting for them to see. 4. The mother squeezes her nipples during manual expression. 97. A client’s vital signs and reflexes were normal throughout pregnancy, labor, and delivery. Four hours after delivery the client’s vitals are 98.6˚F, P 72, R 20, BP 150/100, and her reflexes are 4. She has an intravenous infusion running with 20 units of Pitocin (oxytocin) added. Which of the following actions by the nurse is appropriate? 1. Nothing because the results are normal. 2. Notify the obstetrician of the findings. 3. Discontinue the intravenous immediately. 4. Reassess the client after fifteen minutes. 98. A nurse is caring for a client, PP2, who is preparing to go home with her infant. The nurse notes that the client’s blood type is O (negative), the baby’s type is A (positive), and the direct Coombs’ test 3. Transport the baby to the morgue as soon as possible. 4. Give the parents a lock of the baby’s hair and a copy of the footprint sheet. 100. The nurse is circulating on a cesarean delivery of a G5P4004. All of the client’s previous children were delivered via cesarean section. The physician declares after delivering the placenta that it appears that the client has a placenta accreta. Which of the following maternal complications would be consistent with this diagnosis? 1. Blood loss of 2000 mL. 2. Blood pressure of 160/110. 3. Jaundice skin color. 4. Shortened prothrombin time.