Ati lpn ob maternal newborn
Total Questions : 28
Showing 25 questions, Sign in for moreA nurse is caring for a client who is 1 day postpartum following a cesarean birth.To prevent thrombophlebitis, the nurse should contribute which of the following interventions to the client’s plan of care?
Explanation
Choice A rationale
Ambulation is crucial in preventing thrombophlebitis as it promotes blood circulation and prevents blood stasis, which can lead to clot formation.
Choice B rationale
Warm, moist soaks can provide comfort but do not significantly contribute to preventing thrombophlebitis.
Choice C rationale
Bed rest increases the risk of thrombophlebitis due to decreased circulation and blood stasis.
Choice D rationale
Placing pillows under the knees can impede blood flow and increase the risk of clot formation.
In your patients who have sustained an episiotomy or a laceration, your nursing care would include? (Select all that apply.)
Explanation
Choice A rationale
Topical creams can help soothe and promote healing of the episiotomy or laceration site.
Choice B rationale
Sitz baths are effective in reducing pain and promoting healing by increasing blood flow to the perineal area.
Choice C rationale
Ice packs help reduce swelling and provide pain relief in the initial 24 hours post-delivery.
Choice D rationale
Tocolytics are not indicated for episiotomy or laceration care as they are used to suppress preterm labor.
Choice E rationale
Doing nothing is not appropriate as it does not address the pain or promote healing.
A nurse is reinforcing discharge instructions for a client.At 4 weeks postpartum, the client should contact the provider for which of the following client findings?
Explanation
Choice A rationale
Sore nipples with cracks and fissures can indicate an infection or improper breastfeeding technique, requiring medical attention.
Choice B rationale
Scant nonodorous white vaginal discharge is normal postpartum and does not require contacting the provider.
Choice C rationale
Uterine cramping during breastfeeding is a normal physiological response due to oxytocin release.
Choice D rationale
Decreased response with sexual activity can be normal postpartum and does not necessarily require immediate medical attention.
A nurse is caring for a postpartum client who saturates a perineal pad in 10 minutes.Which of the following actions should the nurse take first?
Explanation
Choice A rationale
Checking blood pressure is important but not the first action to control bleeding.
Choice B rationale
Observing the client is necessary but not the immediate action to control bleeding.
Choice C rationale
Massaging the fundus helps the uterus contract and can reduce bleeding, which is crucial in managing postpartum hemorrhage.
Choice D rationale
Administering oxytocin is important but should follow fundal massage to ensure the uterus is contracting.
A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client’s perineal pad.Which of the following actions should the nurse take first?
Explanation
Choice C rationale
Checking the fundus helps determine if the uterus is contracting properly, which is essential in managing postpartum bleeding.
Choice A rationale
Measuring vital signs is important but not the first action to control bleeding.
Choice B rationale
Requesting a vaginal examination is necessary but not the immediate action to control bleeding.
Choice D rationale
Feeling for a full bladder is important but not the first action to control bleeding.
A client who is 7 days postpartum calls the provider’s office and reports pain, swelling, and redness of her left calf.Besides the client seeing the provider, which of the following interventions should the nurse suggest?
Explanation
Choice A rationale
Massaging the area is not recommended as it can dislodge a clot and cause it to travel to the lungs, leading to a pulmonary embolism. This can be life-threatening and should be avoided.
Choice B rationale
Elevating the leg helps to reduce swelling and pain by promoting venous return. This is a standard intervention for managing symptoms of deep vein thrombosis (DVT) and helps prevent further complications.
Choice C rationale
Applying cold compresses is not effective for DVT. Cold compresses are generally used to reduce inflammation and pain in acute injuries, but they do not address the underlying issue of a blood clot.
Choice D rationale
Flexing the knee while resting can increase the risk of clot dislodgement and is not recommended. Keeping the leg straight and elevated is a safer approach to managing DVT symptoms.
During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops.On data collection, a nurse finds the uterus to be firm, midline, and at the level of the umbilicus.Which of the following findings should the nurse interpret this data as being?
Explanation
Choice A rationale
A cervical or perineal laceration would typically result in continuous bleeding rather than a gush that stops. The uterus would also not be firm and midline if there were a significant laceration.
Choice B rationale
Abnormally excessive lochia rubra flow would be continuous and not stop after a gush. The uterus being firm and midline indicates that the bleeding is not excessive.
Choice C rationale
A normal postural discharge of lochia occurs when pooled blood in the vagina is expelled upon standing or changing position. This is common and expected in the postpartum period.
Choice D rationale
A vaginal hematoma would present with localized pain and swelling, and the bleeding would not stop suddenly. The uterus being firm and midline also indicates that a hematoma is unlikely.
A nurse is reinforcing discharge teaching with a client who is 2 days postpartum and has a history of postpartum depression.Which of the following instructions should the nurse include?
Explanation
Choice A rationale
Staying home until one week after delivery is not a specific intervention for postpartum depression. Social support and monitoring are more effective strategies.
Choice B rationale
While adequate rest is important, advising to sleep as much as possible is not a targeted intervention for postpartum depression. Structured support and counseling are more beneficial.
Choice C rationale
Returning to work two weeks after delivery is not advisable for someone with a history of postpartum depression. Early return to work can increase stress and exacerbate symptoms.
Choice D rationale
Contacting a crisis counselor once a week provides structured support and monitoring, which is crucial for managing postpartum depression. Regular counseling helps in early identification and management of symptoms.
A new mother who is bottle feeding says that she is happy to not have to use birth control for several months after having a baby.What should the nurse say in response?
Explanation
Choice A rationale
It is incorrect to say that birth control is not needed for at least six months. Ovulation can occur much sooner, and contraception should be discussed early.
Choice B rationale
Most people do not need birth control for three months is also incorrect. Ovulation can resume as early as three weeks postpartum.
Choice C rationale
Ovulation can occur within 27 days postpartum, making it important to discuss contraception early to prevent unintended pregnancies.
Choice D rationale
Agreeing with the statement is incorrect and can lead to misinformation. It is important to provide accurate information about postpartum ovulation and contraception.
After a client has a C-section she needs to get up and take short walks to prevent what?
Explanation
Choice A rationale
Hemorrhage is not prevented by walking. Hemorrhage management involves monitoring and medical interventions, not ambulation.
Choice B rationale
Walking helps prevent blood clots by promoting circulation. Postoperative patients are encouraged to ambulate early to reduce the risk of deep vein thrombosis (DVT) and pulmonary embolism.
Choice C rationale
Breast engorgement is managed through breastfeeding or pumping, not walking. Ambulation does not directly affect breast engorgement.
Choice D rationale
Rupture of amniotic membranes is not relevant postpartum. This condition is related to labor and delivery, not postoperative care.
The nurse working in a women’s clinic admits a patient who is almost 6 weeks postpartum and describes a yellow-white vaginal drainage.The nurse interprets this as indicating what?
Explanation
Choice A rationale
Fungal infections typically present with itching, redness, and a thick, white discharge resembling cottage cheese. The yellow-white vaginal drainage described is more consistent with lochia alba, the final stage of lochia, which is a normal postpartum discharge.
Choice B rationale
Lochia alba is the final stage of lochia, occurring around 10 to 14 days postpartum and lasting up to six weeks. It is characterized by a yellowish-white discharge, indicating the end of the postpartum bleeding process.
Choice C rationale
Retained placenta can cause prolonged bleeding and infection, but it is usually associated with heavy bleeding and not a yellow-white discharge. The presence of lochia alba suggests normal postpartum progression.
Choice D rationale
Bacterial infections often present with a foul-smelling discharge, pain, and fever. The yellow-white discharge described is more indicative of lochia alba, a normal postpartum occurrence.
A nurse is assisting a client out of bed for the first time since delivery.The client becomes frightened when she passes a large amount of lochia.Which of the following responses should the nurse make?
Explanation
Choice A rationale
Urinary tract infections (UTIs) are not typically associated with increased lochia. UTIs usually present with symptoms such as burning during urination, frequent urination, and lower abdominal pain.
Choice B rationale
Lochia can pool in the vagina while lying in bed, leading to a larger amount being expelled upon standing. This is a normal occurrence and not a cause for concern.
Choice C rationale
Retained fragments of the placenta can cause heavy bleeding and infection, but the sudden expulsion of a large amount of lochia upon standing is more likely due to pooling rather than retained placenta.
Choice D rationale
The amount of lochia typically decreases over time during the postpartum period. An increase in lochia is not expected and should be evaluated for other causes.
A nurse is reinforcing teaching with a client who is breastfeeding and has mastitis.Which of the following responses should the nurse make?
Explanation
Choice A rationale
Completely emptying each breast at each feeding or using a pump helps prevent milk stasis, which can lead to mastitis. Ensuring the breasts are fully emptied reduces the risk of blocked ducts and infection.
Choice B rationale
Nursing on only the unaffected breast can lead to engorgement and worsening of mastitis in the affected breast. It is important to continue breastfeeding on both sides to maintain milk flow and prevent complications.
Choice C rationale
Wearing a tight-fitting bra can restrict milk flow and exacerbate mastitis. A well-fitting, supportive bra is recommended to avoid further complications.
Choice D rationale
Limiting the time the infant nurses on each breast can lead to incomplete emptying and increase the risk of mastitis. It is important to ensure the breasts are fully emptied to prevent infection.
A nurse is caring for a client who just delivered a stillborn infant at 36 weeks gestation.Which of the following responses should the nurse make?
Explanation
Choice A rationale
While sharing personal experiences can sometimes be comforting, it may not always be appropriate or helpful in a professional setting. The focus should be on the patient’s needs and feelings.
Choice B rationale
Calling for a chaplain can be supportive, but it is important to first offer the parents the opportunity to hold their baby and spend time with them, which can be an important part of the grieving process.
Choice C rationale
Allowing the parents to hold their baby for as long as they want provides them with the opportunity to say goodbye and can be a crucial part of the grieving process. It helps them to acknowledge their loss and begin to process their emotions.
Choice D rationale
Telling the parents that the loss is for the best is not supportive and can be hurtful. It is important to validate their feelings and provide compassionate care during this difficult time.
A nurse is caring for a client who is 2 weeks postpartum.The client tells the nurse, “I feel really down and sad lately.I have no energy and I feel like I’m going to cry.”. Which of the following actions should the nurse take first?
Explanation
Choice D rationale
Using a postpartum depression-screening tool with the client is the first action the nurse should take. This tool helps to assess the severity of the client’s symptoms and determine the appropriate level of care. Early identification and intervention are crucial in managing postpartum depression effectively.
Choice A rationale
Arranging for counseling to help the client cope with the stress of being a parent is important, but it is not the first action. Counseling can be part of the treatment plan after the initial assessment using the screening tool.
Choice B rationale
Reinforcing teaching about ways to increase rest and sleep is beneficial for the client’s overall well-being, but it does not address the immediate need to assess the severity of the client’s depressive symptoms.
Choice C rationale
Requesting a prescription for an antidepressant medication may be necessary, but it should be based on the results of the screening tool and a thorough assessment by a healthcare provider.
A nurse is collecting data from a client who is postpartum.Which of the following findings should alert the nurse to the possibility of a postpartum complication?
Explanation
Choice B rationale
A heart rate of 110/min is a sign of tachycardia, which can indicate a postpartum complication such as infection, hemorrhage, or other underlying conditions. Tachycardia requires immediate assessment and intervention.
Choice A rationale
Chills shortly following delivery can be a normal response to the body’s adjustment after childbirth and do not necessarily indicate a complication.
Choice C rationale
Urinary output of 3,000 mL/12 hr is high but can be a normal part of postpartum diuresis as the body eliminates excess fluid accumulated during pregnancy.
Choice D rationale
The fundus at the umbilicus level is a normal finding in the immediate postpartum period and does not indicate a complication.
A nurse is caring for a client who has unrelieved episiotomy pain 8 hr following delivery.Which of the following actions should the nurse take?
Explanation
Choice D rationale
Applying an ice pack to the perineum is the recommended action for unrelieved episiotomy pain within the first 24 hours following delivery. Ice helps reduce swelling and provides pain relief.
Choice A rationale
Placing a soft pillow under the client’s buttocks is not effective and can increase pressure and swelling on the perineal area, worsening the pain.
Choice B rationale
Positioning a heating lamp toward the episiotomy is not recommended as it can increase the risk of burns and does not effectively reduce swelling.
Choice C rationale
Preparing a warm sitz bath can be beneficial after the first 24 hours but is not the initial action for unrelieved pain within the first 8 hours.
A nurse is collecting data from a client who gave birth 12 hr ago.The nurse notes the fundus is deviated to the right, boggy, and 2 cm above the umbilicus.Which of the following actions should the nurse take first?
Explanation
Choice D rationale
Assisting the client to void is the first action the nurse should take. A full bladder can cause the fundus to deviate to the right and become boggy. Voiding helps the uterus contract and return to its normal position.
Choice A rationale
Inserting an indwelling urinary catheter may be necessary if the client is unable to void, but it is not the first action.
Choice B rationale
Administering methylergometrine to the client is not the first action. This medication stimulates uterine contractions and can help reduce postpartum bleeding, but the initial step is to address the full bladder.
Choice C rationale
Obtaining a stat hemoglobin level is important if there is a concern for significant blood loss, but it is not the first action.
A nurse is assisting with the care of a postpartum client who is exhibiting tearfulness, insomnia, lack of appetite, and a feeling of letdown.Which of the following conditions are associated with these manifestations?
Explanation
Choice C rationale
Postpartum blues are characterized by tearfulness, insomnia, lack of appetite, and a feeling of letdown. These symptoms are common and usually resolve within a few weeks without medical intervention.
Choice A rationale
The letting-go phase occurs when the woman has assumed responsibility for caring for herself and her infant. It is not associated with the symptoms described.
Choice B rationale
Postpartum fatigue can cause tiredness and lack of energy but does not typically include tearfulness and a feeling of letdown.
Choice D rationale
Postpartum psychosis is a severe mental health condition that includes symptoms such as hallucinations, delusions, and severe mood swings. It is not characterized by the milder symptoms described. .
A nurse is contributing to the plan of care for a client who is postpartum and has thrombophlebitis.Which of the following nursing interventions should the nurse recommend?
Explanation
Choice A rationale
Measuring leg circumferences is a crucial intervention for a client with thrombophlebitis. This helps in monitoring for any increase in swelling, which can indicate worsening of the condition or the development of complications such as deep vein thrombosis (DVT). Regular measurement allows for early detection and timely intervention.
Choice B rationale
Massaging the affected extremity is contraindicated in clients with thrombophlebitis. Massage can dislodge a thrombus, leading to a potentially life-threatening pulmonary embolism. Therefore, this intervention should be avoided.
Choice C rationale
Applying cold compresses to the affected extremity is not recommended for thrombophlebitis. Cold compresses can cause vasoconstriction, which may worsen the condition by reducing blood flow and increasing the risk of clot formation.
Choice D rationale
Allowing the client to ambulate is not advisable in the acute phase of thrombophlebitis. Ambulation can increase the risk of thrombus dislodgement and subsequent pulmonary embolism. Bed rest with the affected limb elevated is usually recommended until the acute phase resolves.
A nurse is collecting data from a client who is 1 day postpartum.Which of the following findings requires immediate intervention by the nurse?
Explanation
Choice A rationale
A decreased urge to void is a common postpartum finding due to the effects of anesthesia and the trauma of childbirth. It does not require immediate intervention unless it leads to bladder distention.
Choice B rationale
A displaced fundus from the midline, especially if it is accompanied by a boggy uterus, indicates uterine atony, which can lead to postpartum hemorrhage. Immediate intervention is required to prevent severe blood loss.
Choice C rationale
A fundal height below the umbilicus is an expected finding 1 day postpartum as the uterus begins to involute. This does not require immediate intervention.
Choice D rationale
Increased urine output is common in the postpartum period as the body eliminates excess fluid accumulated during pregnancy. This is not a cause for immediate concern.
A nurse is collecting data from a client who is 3 hr postpartum.The nurse notes that the client’s fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus.Which of the following actions should the nurse take?
Explanation
Choice A rationale
Inserting a urinary catheter is not the first action to take when the fundus is displaced to the right of midline. The displacement is often due to a full bladder, and the client should be encouraged to void first.
Choice B rationale
Massaging the fundus is appropriate if the uterus is boggy, but in this case, the fundus is firm. The displacement is likely due to a full bladder.
Choice C rationale
Having the client urinate is the correct action. A full bladder can displace the uterus and prevent it from contracting properly, which can lead to postpartum hemorrhage.
Choice D rationale
Administering analgesia is not relevant to the issue of a displaced fundus. The priority is to address the cause of the displacement, which is likely a full bladder.
A nurse is caring for a client who is postpartum.Which of the following findings is an indication for the nurse to administer Rho(D) immune globulin?
Explanation
Choice A rationale
Rho(D) immune globulin is not indicated if both the client and the newborn are Rh positive. There is no risk of Rh incompatibility in this scenario.
Choice B rationale
Similarly, if both the client and the newborn are Rh positive, there is no need for Rho(D) immune globulin.
Choice C rationale
If both the client and the newborn are Rh negative, there is no risk of Rh incompatibility, and Rho(D) immune globulin is not needed.
Choice D rationale
Rho(D) immune globulin is indicated when the client is Rh negative and the newborn is Rh positive. This prevents the development of Rh antibodies in the client, which could affect future pregnancies.
A nurse is reinforcing postpartum discharge teaching to a client who had no immunity to varicella and was given the varicella vaccine.Which of the following statements by the client indicates understanding?
Explanation
Choice A rationale
The client needs a second varicella vaccination at her postpartum visit to ensure full immunity. The initial dose provides partial immunity, and the second dose completes the vaccination series.
Choice B rationale
The client needs to use contraception for 1 month, not 3 months, before considering pregnancy after receiving the varicella vaccine. This is to prevent potential harm to a developing fetus.
Choice C rationale
The varicella vaccine is not given based on the baby’s blood type. It is administered to protect the client from varicella infection.
Choice D rationale
There is no need for testing to see if the client has developed immunity after receiving the varicella vaccine. The second dose is given to ensure full immunity.
A nurse is collecting data from a client who is 3 days postpartum and is breastfeeding.Her fundus is three fingerbreadths below the umbilicus, and her lochia rubra is moderate.Her breasts feel hard and warm.Which of the following recommendations should the nurse give the client?
Explanation
Choice A rationale
Obtaining a prescription for an antibiotic is not the first recommendation for a client who is 3 days postpartum and breastfeeding with hard and warm breasts. Antibiotics are typically prescribed if there is a confirmed infection, such as mastitis, which is characterized by symptoms like fever, chills, and flu-like symptoms. In this case, the client is experiencing normal postpartum breast engorgement, which does not require antibiotics.
Choice B rationale
Expressing milk from both breasts is the correct recommendation. Breast engorgement is common in the early postpartum period as the milk comes in. Expressing milk, either by breastfeeding frequently or using a breast pump, helps to relieve the fullness, reduce discomfort, and maintain milk production.
Choice C rationale
Wearing a nipple shield is not recommended for breast engorgement. Nipple shields are typically used for issues like latch difficulties or sore nipples, not for relieving engorgement. Using a nipple shield without proper guidance can potentially interfere with milk transfer and breastfeeding success.
Choice D rationale
Applying a heating pad to the breasts is not recommended for engorgement. Heat can increase blood flow and exacerbate swelling. Instead, cold compresses or cold cabbage leaves are often recommended to reduce swelling and discomfort associated with engorgement.
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