NURS 1102 Passpoint-postpartum | Download To Score An A.

Passpoint-postpartum. Question 1 See full question A client gives birth to a stillborn neonate at 36 weeks' gestation. When caring for this client, which strategy by the nurse would be most helpful? You Selected: • ...

Passpoint-postpartum. Question 1 See full question A client gives birth to a stillborn neonate at 36 weeks' gestation. When caring for this client, which strategy by the nurse would be most helpful? You Selected: • Provide information about possible causes of the stillbirth only if the client requests it. Correct response: • Encourage the client to see, touch, and hold the dead neonate. Explanation: Remediation: Question 2 See full question During the postpartum period, a nurse should assess for signs of normal involution. Which statement would indicate that a client is progressing normally? You Selected: • Perineal pad usage remains at 10 to 15 per day. Correct response: • The uterus is descending at the rate of one fingerbreadth per day. Explanation: Remediation: Question 3 See full question Which response would be most appropriate for the nurse when comforting a primiparous client whose critically ill neonate delivered at 25 weeks dies while the mother is present? You Selected: • "You can stay with your baby as long as you want and say anything you want." Correct response: • "You can stay with your baby as long as you want and say anything you want." Explanation: Remediation: Question 4 See full question While the nurse is caring for a primiparous client on the first postpartum day, the client asks, “How is that woman doing who lost her baby from prematurity? We were in labor together.” Which response by the nurse would be most appropriate? You Selected: • Tell the client “I’m not sure how the other woman is doing today.” Correct response: • Explain to the client that “Nurses are not allowed to discuss other clients on the unit.” Explanation: Remediation: Question 1 See full question A client gave birth to a healthy full-term girl 2 hours ago by cesarean birth. When assessing this client, which finding requires immediate nursing action? You Selected: • Tachycardia and hypotension Correct response: • Tachycardia and hypotension Explanation: Remediation: Question 2 See full question Lochia normally progresses in which pattern? You Selected: • Rubra, serosa, alba Correct response: • Rubra, serosa, alba Explanation: Remediation: Question 3 See full question A client who had a cesarean birth 1 day ago asks for pain medication when the nurse enters the room to perform her shift assessment. The client states that her pain level is an 8 on a 0-to-10-point scale. The priority of care should be for the nurse to: You Selected: • administer any ordered pain medication. Correct response: • administer any ordered pain medication. Explanation: Remediation: Question 4 See full question While the nurse is caring for a primiparous client on the first postpartum day, the client asks, “How is that woman doing who lost her baby from prematurity? We were in labor together.” Which response by the nurse would be most appropriate? You Selected: • Explain to the client that “Nurses are not allowed to discuss other clients on the unit.” Correct response: • Explain to the client that “Nurses are not allowed to discuss other clients on the unit.” Explanation: Remediation: Question 5 See full question While changing the neonate’s diaper, the client asks the nurse about some red-tinged drainage from the neonate’s vagina. Which response would be most appropriate? You Selected: • “Sometimes baby girls have this from hormones received from the mother.” Correct response: • “Sometimes baby girls have this from hormones received from the mother.” Explanation: Remediation: Question 5 See full question While making a home visit to a multigravida 2 weeks after the birth of viable twins at 38 weeks’ gestation, the nurse observes that the client looks pale, has dark circles around her eyes, and is breastfeeding one of the twins. The client’s apartment is clean, and nothing appears out of place. The client tells the nurse that she completed three loads of laundry this morning. A priority need for this client is: You Selected: • possible anemia related to large volume of blood loss and twin birth. Correct response: • fatigue related to home maintenance and caring for twins. Explanation: /.modal - - - - - - - - - - - - - - - - - - - - - - - - Footer - - - - - - - - - - - - - - - - - - - - - - - - - Question 1 See full question A client is at the end of her first postpartum day. The nurse is assessing the client's uterus. Which finding requires further evaluation? You Selected: • Fundus two fingerbreadths above the umbilicus Correct response: • Fundus two fingerbreadths above the umbilicus Explanation: Remediation: Question 2 See full question A nurse is assessing the parent-neonate attachment of postpartum clients. Which finding most indicates a need for further evaluation? You Selected: • Limited parent-neonate contact immediately after birth Correct response: • Limited parent-neonate contact immediately after birth Explanation: Remediation: Question 3 See full question A nurse encourages a postpartum client to discuss the childbirth experience. Which client outcome is most appropriate for this client? You Selected: • "The client demonstrates an understanding of the neonate's physical needs related to labor and birth." Correct response: • "The client demonstrates the ability to integrate the childbirth experience and progress to the task of maternal role attainment." Explanation: Remediation: Question 4 See full question Lochia normally progresses in which pattern? You Selected: • Rubra, serosa, alba Correct response: • Rubra, serosa, alba Explanation: Remediation: Question 5 See full question When caring for a multiparous client who is human immunodeficiency virus (HIV)–positive and asking to breastfeed her neonate as soon as possible, which information about breast milk should the nurse include in the teaching plan? You Selected: • It has been found to contain the retrovirus HIV. Correct response: • It has been found to contain the retrovirus HIV. Explanation: Remediation: A client who gave birth 24 hours ago continues to experience urine retention after several catheterizations. The physician orders bethanechol, 10 mg by mouth three times per day. The client asks, "How does bethanechol act on the bladder?" How should the nurse respond? You Selected: • "It stimulates the smooth muscle of the bladder." Correct response: • "It stimulates the smooth muscle of the bladder." Explanation: Remediation: Question 2 See full question A nurse is assessing a client on the second postpartum day. Upon palpation, the nurse discovers that the fundus is deviated to the right. To further investigate this finding, what should the nurse ask the client? You Selected: • "Are you having afterpains?" Correct response: • "Have you voided recently?" Explanation: Remediation: Question 3 See full question When caring for a client who has recently given birth, the nurse assesses the client for urinary retention with overflow. Which sign or symptom provides the most accurate picture of retention with overflow? You Selected: • A varying urge to urinate with an average output of 100 ml Correct response: • A varying urge to urinate with an average output of 100 ml Explanation: Remediation: Question 4 See full question When caring for a multiparous client who is human immunodeficiency virus (HIV)–positive and asking to breastfeed her neonate as soon as possible, which information about breast milk should the nurse include in the teaching plan? You Selected: • It has been found to contain the retrovirus HIV. Correct response: • It has been found to contain the retrovirus HIV. Explanation: Remediation: Question 5 See full question A nurse meets his/her neighbor and new baby at the local market. The neighbor states that she received outstanding nursing care from one of the nurse's colleagues during her labor and childbirth. What is the best way for the nurse to recognize her nursing colleague’s professional efforts? You Selected: • Post accolades to the nurse at the nurses’ station. Correct response: • Share the feedback with the nursing colleague directly. Explanation: /.modal - - - - - - - - - - - - - - - - - - - - - - - - Footer - - - - - - - - - - - - - - - - - - - - - - - - - Question 6 See full question An adolescent primiparous client 24 hours postpartum asks the nurse how often she can hold her baby without “spoiling” him. Which response would be most appropriate? You Selected: • “Hold him as much as you want to hold him.” Correct response: • “Hold him as much as you want to hold him.” Explanation: Remediation: Question 7 See full question While assisting a primiparous client with her first breastfeeding session, which action should the nurse instruct the mother to do to stimulate the neonate to open the mouth and grasp the nipple? You Selected: • Brush the neonate’s lips lightly with the nipple. Correct response: • Brush the neonate’s lips lightly with the nipple. Explanation: Remediation: Question 8 See full question After giving birth to a viable neonate 12 hours ago, the client’s fundus is firm at midline, and her breasts are soft. She has scant lochia and she is voiding sufficiently. The client reports pain in her lower back. What should the nurse do next? You Selected: • Administer a prescribed mild analgesic. Correct response: • Administer a prescribed mild analgesic. Explanation: Remediation: Question 9 See full question A client and her partner just experienced spontaneous bleeding at 11 weeks gestation, which resulted in the loss of the fetus. The couple wonders if the bleeding could have been caused from the client working long hours in a stressful work environment. What is the most appropriate response from the nurse? You Selected: • “I can understand your need to find an answer to what caused this. Let’s talk about this further.” Correct response: • “I can understand your need to find an answer to what caused this. Let’s talk about this further.” Explanation: Remediation: Question 10 See full question The nurse is educating an expectant mother about breastfeeding. What statement made by the mother would prevent the mother from breastfeeding the newborn? You Selected: • “I have been HIV positive for 4 years.” Correct response: • “I have been HIV positive for 4 years.” Question 1 See full question A nurse is teaching a client about hormonal contraceptive therapy. If a client misses three or more pills in a row, the nurse should instruct the client to: You Selected: • take all the missed doses as soon as she discovers the oversight. Correct response: • discard the pack, use an alternative contraceptive method until her period begins, and start a new pack on the regular schedule. Explanation: Remediation: Question 2 See full question During a home visit on the fifth postpartum day, the client begins to cry and says that she is worried about her ability to care for her baby adequately. She tells the nurse, “I wish I could just get organized—I need 8 hours of sleep!” The nurse determines that she is experiencing which condition? You Selected: • Postpartum blues phase of childbearing; she needs psychological counseling. Correct response: • Taking-hold phase of childbearing; she is feeling inadequate about neonatal care. Explanation: Remediation: Question 3 See full question A 24-year-old primipara decides to breastfeed her baby but says, “I am worried that I will not be able to breastfeed my baby because my breasts are so small.” What would the nurse include in the explanation to the client? You Selected: • The woman's motivation to breast-feed is more important than breast size. Correct response: • Breast size poses no influence on a woman's ability to breastfeed a baby. Explanation: Remediation: Question 4 See full question On the first postpartum day after a cesarean birth, the client is prescribed a full liquid diet as tolerated. Before providing a full liquid breakfast, the nurse should assess which factor? You Selected: • desire to eat Correct response: • bowel sounds Explanation: Remediation: Question 5 See full question While assisting a multiparous client to the bathroom for the first time 1 hour after a vaginal birth of a viable neonate, the nurse notes that the client’s urine has two small blood clots in the measuring container. What should the nurse do next? You Selected: • Document this observation as a normal finding. Correct response: • Document this observation as a normal finding. Explanation: Remediation: Question 6 See full question Twenty-four hours after giving birth to a term neonate, a primipara receives acetaminophen with codeine for perineal pain. One hour after administering the medication, which finding should alert the nurse to the development of a possible side effect? You Selected: • dizziness Correct response: • dizziness Explanation: Question 7 See full question Which client statement indicates effective teaching about burping a breastfed neonate? You Selected: • “Breastfed babies who are burped frequently will take more on each breast.” Correct response: • “When I switch to the other breast, I’ll burp the baby.” Explanation: Remediation: Question 8 See full question A nurse is assisting a grieving client and his/her spouse to deal with their loss of their 24-week-old infant. Which of the following actions would be most appropriate from the nurse? Select all that apply. You Selected: • Provide an early opportunity for the couple to see their child if they desire. • Answer the parents’ questions accurately. • Offer to stay with the grieving parents. Correct response: • Provide an early opportunity for the couple to see their child if they desire. • Offer to stay with the grieving parents. • Answer the parents’ questions accurately. Explanation: Remediation: Question 9 See full question A postpartum client tells the nurse that she and her husband had an argument about continuing breastfeeding before he left for work in the morning. He was up all night, not able to sleep with the baby crying, and he wants the client to give the baby formula. What is the most appropriate immediate response from the nurse? You Selected: • “What are your feelings about breastfeeding?” Correct response: • “What are your feelings about breastfeeding?” Explanation: Remediation: Question 1 See full question A client with cardiac disease gives birth. Afterward, the nurse assesses the client for signs and symptoms of cardiac decompensation. During the postpartum period, which assessment finding indicates a need for further investigation? You Selected: • Diuresis Correct response: • Tachycardia Explanation: Remediation: Question 2 See full question Rho (D) immune globulin (RhoGAM) is prescribed for a client before she is discharged after a spontaneous abortion. The nurse instructs the client that this drug is used to prevent which condition? You Selected: • development of Rh-positive antibodies Correct response: • development of Rh-positive antibodies Explanation: Remediation: Question 3 See full question Three hours postpartum, a primiparous client’s fundus is firm and midline. On perineal inspection, the nurse observes a small, constant trickle of blood. Which condition should the nurse assess further? You Selected: • perineal lacerations Correct response: • perineal lacerations Explanation: Remediation: Question 4 See full question The nurse is evaluating the client who gave birth vaginally 2 hours ago and is experiencing postpartum pain rated 8 on scale of 1 to 10. The client is a multigravida breastfeeding mother who would like medication to decrease the pain in her uterus. Which of the medications listed on the prescriptions sheet would be the most appropriate for this client? You Selected: • ibuprofen 800 mg PO every 6 to 8 hour PRN Correct response: • acetaminophen and hydrocodone 10 mg 1 tab PO every 4 to 6 hour PRN Explanation: Remediation: Question 5 See full question A nurse is assisting a grieving client and his/her spouse to deal with their loss of their 24-week-old infant. Which of the following actions would be most appropriate from the nurse? Select all that apply. You Selected: • Answer the parents’ questions accurately. • Offer to stay with the grieving parents. • Provide an early opportunity for the couple to see their child if they desire. Correct response: • Provide an early opportunity for the couple to see their child if they desire. • Offer to stay with the grieving parents. • Answer the parents’ questions accurately. Explanation: question 1 See full question As she tries to decide on a birth control method, a client requests information about medroxyprogesterone. Which statement represents the nurse's best response? You Selected: • Medroxyprogesterone needs to be administered every 12 weeks. Correct response: • Medroxyprogesterone needs to be administered every 12 weeks. Explanation: Remediation: Question 2 See full question A client whose blood type is A− gives birth to a neonate whose blood type is A+. The client is scheduled to have Rho(D) immune globulin administered. Before administering the medication, which action by the nurse is most important? You Selected: • Ensuring that the client understands the procedure and signs a consent for the vaccination Correct response: • Ensuring that the client understands the procedure and signs a consent for the vaccination Explanation: Remediation: Question 3 See full question While assessing the fundus of a multiparous client on the first postpartum day, the nurse performs handwashing and dons clean gloves. What should the nurse do next? You Selected: • Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus. Correct response: • Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus. Explanation: Remediation: Question 4 See full question During the immediate postpartum period after giving birth to twins, the client experiences uterine atony. What should the nurse do first? You Selected: • Gently massage the fundus. Correct response: • Gently massage the fundus. Explanation: Remediation: Question 5 See full question A postpartum client tells the nurse that she and her husband had an argument about continuing breastfeeding before he left for work in the morning. He was up all night, not able to sleep with the baby crying, and he wants the client to give the baby formula. What is the most appropriate immediate response from the nurse? You Selected: • “What are your feelings about breastfeeding?” Correct response: • “What are your feelings about breastfeeding?” Explanation: Remediatio Question 1 See full question Which statement summarizes the underlying principle for the development of a parent-child relationship? You Selected: • The relationship is part of the adult maturational process. Correct response: • The relationship is based on the need for early and frequent parent-infant contact. Explanation: Remediation: Question 2 See full question Four hours after cesarean birth of a neonate weighing 8 lb, 13 oz (4,000 g), the primiparous client asks, “If I get pregnant again, will I need to have a cesarean?” When responding to the client, the nurse should base the response to the client about vaginal birth after cesarean (VBAC) on which standard of practice? You Selected: • VBAC may be possible if the client has not had a classic uterine incision. Correct response: • VBAC may be possible if the client has not had a classic uterine incision. Explanation: Remediation: Question 3 See full question The community health nurse has a student nurse with him/her for the day. The RN asks the parents at the home visit if the student can be present for the breastfeeding assessment. The husband declines this opportunity. What is the nurse’s most appropriate response? You Selected: • Honor the father's preference. Correct response: • Honor the father's preference. Explanation: Remediation: Question 4 See full question A client and her partner just experienced spontaneous bleeding at 11 weeks gestation, which resulted in the loss of the fetus. The couple wonders if the bleeding could have been caused from the client working long hours in a stressful work environment. What is the most appropriate response from the nurse? You Selected: • “I can understand your need to find an answer to what caused this. Let’s talk about this further.” Correct response: • “I can understand your need to find an answer to what caused this. Let’s talk about this further.” Explanation: Remediation: Question 5 See full question The nurse is caring for a woman in the fourth stage of labor who continues to hemorrhage after fundal massage. Which of the following interventions should the nurse provide to decrease the bleeding? You Selected: • Increase the rate of oxytocin Correct response: • Have the client empty her bladder Explanation: Remediation: /.modal - - - - - - - - - - - - - - - - - - - - - - - - Footer - - - - - - - - - - - - - - - - - - - - - - - - - Question 10 See full question A client is breastfeeding her newborn infant. The client’s nipples are red and bruised, and a small crack is visible on the right nipple. Which of the following interventions should the nurse do next? You Selected: • Assist the client to have the infant create a correct latch to the breast. Correct response: • Assist the client to have the infant create a correct latch to the breast. COMPLETED IN4m 20s CORRECTLY ANSWERED8 of 10 questions • Take a Practice Quiz • See your Overall Performance • See your Quiz History Performance by nursing topic What's this? Postpartum Period 3 quizzes taken 2 Your mastery 7.29 Class average View performance for all nursing topics Answer Key Question 1 See full question Normal lochial findings in the first 24 hours after birth include: You Selected: • bright red blood. Correct response: • bright red blood. Explanation: Remediation: Question 2 See full question In the maternal attachment process, which statement best describes the anticipated actions in the taking-hold phase? You Selected: • Talking about the neonate Correct response: • Kissing, embracing, and caring for the neonate Explanation: Remediation: Question 3 See full question A primiparous client, who has just given birth to a healthy term neonate after 12 hours of labor, holds and looks at her neonate and begins to cry. The nurse interprets this behavior as a sign of which response? You Selected: • a normal response to the birth Correct response: • a normal response to the birth Explanation: Remediation: Question 4 See full question After the first breastfeeding, the client asks the nurse, “How often should I try to breastfeed?” What frequency should the nurse recommend? You Selected: • every 2 to 3 hours for the first 48 hours Correct response: • every 2 to 3 hours for the first 48 hours Explanation: Remediation: Question 5 See full question The nurse is caring for a 22-year-old G2, P2 client who has disseminated intravascular coagulation after delivering a dead fetus. Which finding is the highest priority to report to the health care provider (HCP)? You Selected: • urinary output of 25 mL in the past hour Correct response: • urinary output of 25 mL in the past hour Explanation: Remediation: Question 6 See full question Prophylactic heparin therapy is prescribed to treat thrombophlebitis in a multiparous client who gave birth 24 hours ago. After instructing the client about the medication, the nurse determines that the client understands the instructions when she states which as the purpose of the drug? You Selected: • to prevent further blood clot formation Correct response: • to prevent further blood clot formation Explanation: Remediation: Question 7 See full question A primigravid client at 41 weeks' gestation is admitted to the hospital's labor and birth unit in active labor. After 25 hours of labor with membranes ruptured for 24 hours, the client gives birth to a healthy neonate vaginally with a midline episiotomy. Which problem should the nurse identify as the priority for the client? You Selected: • risk for infection Correct response: • risk for infection Explanation: Remediation: Question 1 See full question A client who has received a new prescription for oral contraceptives asks the nurse how to take them. Which symptom should the nurse instruct the client to report to her primary caregiver? You Selected: • Decreased menstrual flow Correct response: • Blurred vision and headache Explanation: Remediation: Question 2 See full question The health care provider (HCP) prescribes an intramuscular injection of vitamin K for a term neonate. The nurse explains to the mother that this medication is used to prevent which problem? You Selected: • hypoglycemia Correct response: • hemorrhage Explanation: Remediation: Question 3 See full question The community health nurse has a student nurse with him/her for the day. The RN asks the parents at the home visit if the student can be present for the breastfeeding assessment. The husband declines this opportunity. What is the nurse’s most appropriate response? You Selected: • Honor the father's preference. Correct response: • Honor the father's preference. Explanation: Remediation: Question 4 See full question A nurse assesses a client who is 16 days postpartum. The nurse finds that the client’s left nipple is cracked and bleeding slightly. Her left breast is sore to touch, and an area under the breast is firm, painful, and red. The client is also experiencing chills. What is likely causing this breastfeeding problem? You Selected: • Mastitis Correct response: • Mastitis Explanation: Remediation: Question 5 See full question The clinic nurse is assessing a postpartum client’s fundus at the umbilicus 2 weeks after giving birth. Which of the following would the nurse include in the client’s plan of care? You Selected: • Assess the client’s legs for thrombophlebitis Correct response: • Assess the client’s bleeding flow and color Explanation: Remediation: /.modal - - - - - - - - - - - - - - - - - - - - - - - - Footer - - - - - - - - - - - - - - - - - - - - - - - - - Question 8 See full question A nurse assesses a client who is 16 days postpartum. The nurse finds that the client’s left nipple is cracked and bleeding slightly. Her left breast is sore to touch, and an area under the breast is firm, painful, and red. The client is also experiencing chills. What is likely causing this breastfeeding problem? You Selected: • Mastitis Correct response: • Mastitis Explanation: Remediation: Question 9 See full question The nurse is assessing a client who is 4 hours postpartum. Based on the findings documented by the nurse, which action is most appropriate at this time? You Selected: • Ask the client to empty her bladder. Correct response: • Ask the client to empty her bladder. Explanation: Remediation: Question 1 See full question A 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? You Selected: • Washing the hands and wearing latex gloves Correct response: • Washing the hands and wearing latex gloves Explanation: Remediation: Question 1 See full question A client who gave birth 24 hours ago continues to experience urine retention after several catheterizations. The physician orders bethanechol, 10 mg by mouth three times per day. The client asks, "How does bethanechol act on the bladder?" How should the nurse respond? You Selected: • "It stimulates the smooth muscle of the bladder." Correct response: • "It stimulates the smooth muscle of the bladder." Explanation: Remediation: Question 2 See full question The nurse is caring for a client on her second postpartum day. The nurse should expect the client's lochia to be: You Selected: • red and moderate. Correct response: • red and moderate. Explanation: Remediation: Question 3 See full question Which response would be most appropriate for the nurse when comforting a primiparous client whose critically ill neonate delivered at 25 weeks dies while the mother is present? You Selected: • "You can stay with your baby as long as you want and say anything you want." Correct response: • "You can stay with your baby as long as you want and say anything you want." Explanation: Remediation: Question 4 See full question Prophylactic heparin therapy is prescribed to treat thrombophlebitis in a multiparous client who gave birth 24 hours ago. After instructing the client about the medication, the nurse determines that the client understands the instructions when she states which as the purpose of the drug? You Selected: • to prevent further blood clot formation Correct response: • to prevent further blood clot formation Explanation: Remediation: Question 5 See full question Which instructions about breastfeeding should the nurse include when counseling the client? You Selected: • Wrap breasts with ace bandages. Correct response: • Use a water-based lubricant when having intercourse. Explanation: Remediation: Question 2 See full question While the nurse is caring for a primiparous client with cephalopelvic disproportion 4 hours after a cesarean birth, the client requests assistance in breastfeeding. To promote maximum maternal comfort, which position would be most appropriate for the nurse to suggest? You Selected: • scissors hold Correct response: • football hold Explanation: Remediation: Question 3 See full question On the second postpartum day after a cesarean birth, the client reports having gas pains. What should the nurse should instruct the client to do? You Selected: • Ambulate more often. Correct response: • Ambulate more often. Explanation: Remediation: Question 4 See full question A postpartum client calls the nurse and informs the nurse that the client “had a baby 1 week ago and still having a pink discharge.” Which of the following is the nurse's best response? You Selected: • “You should not be having any discharge after the third day.” Correct response: • “This is called lochia serosa and is a normal finding for approximately 3–10 days.” Explanation: Remediation: Question 5 See full question The nurse is assessing a client who is 4 hours postpartum. Based on the findings documented by the nurse, which action is most appropriate at this time? You Selected: • Ask the client to empty her bladder. Correct response: • Ask the client to empty her bladder. Explanation: Remediation: /.modal - - - - - - - - - - - - - - - - - - - - - - - - Footer - - - - - - - - - - - - - - - - - - - - - - - - - Question 1 See full question A client gave birth to a healthy full-term girl 2 hours ago by cesarean birth. When assessing this client, which finding requires immediate nursing action? You Selected: • Gush of vaginal blood when she stands up Correct response: • Tachycardia and hypotension Explanation: Remediation: Question 2 See full question A nurse is teaching a client how to perform perineal care to reduce the risk of puerperal infection. Which activity indicates that the client understands proper perineal care? You Selected: • Using a peri bottle to clean the perineum after each voiding or bowel movement Correct response: • Using a peri bottle to clean the perineum after each voiding or bowel movement Explanation: Remediation: Question 3 See full question A client who had a cesarean birth 1 day ago asks for pain medication when the nurse enters the room to perform her shift assessment. The client states that her pain level is an 8 on a 0-to-10-point scale. The priority of care should be for the nurse to: You Selected: • start the postpartum assessment. Correct response: • administer any ordered pain medication. Explanation: Remediation: Question 4 See full question While assisting a multiparous client to the bathroom for the first time 1 hour after a vaginal birth of a viable neonate, the nurse notes that the client’s urine has two small blood clots in the measuring container. What should the nurse do next? You Selected: • Document this observation as a normal finding. Correct response: • Document this observation as a normal finding. Explanation: Remediation: Question 5 See full question A 34-year-old client birthed a healthy baby boy 5 days ago. The client is experiencing insomnia and weepiness, lasting for short periods of time each day. Which of the following factors/conditions does the nurse believe is causing this experience? You Selected: • Postpartum reaction Correct response: • Postpartum baby blues Explanation: Remediation: Question 10 See full question The nurse assesses a client, who delivered vaginally 6 days ago, during a home visit. Which finding should the nurse report immediately to the health care provider (HCP)? Select all that apply. You Selected: • temperature of 100.8° F (38.2° C) • soaking 1 peripad every 3 to 4 hours • foul-smelling lochia Correct response: • foul-smelling lochia • temperature of 100.8° F (38.2° C) Question 1 See full question The nurse is caring for a client on her second postpartum day. The nurse should expect the client's lochia to be: You Selected: • brown and scant. Correct response: • red and moderate. Explanation: Remediation: Question 2 See full question Staff nurses on the postpartum floor are concerned that discharge teaching is consuming a large portion of their time. How can the nurses teach their clients in a more efficient manner? You Selected: • Conduct a class for clients who require the same discharge teaching. Correct response: • Conduct a class for clients who require the same discharge teaching. Explanation: Remediation: Question 3 See full question Antenatal laboratory testing revealed a negative rubella antibody for a client admitted to the postpartum unit. Which action takes priority for this client during early puerperium? You Selected: • Rubella counseling and instruction to obtain live rubella virus vaccine during her first postpartum examination Correct response: • Rubella counseling and immunization with live rubella virus vaccine Explanation: Remediation: Question 4 See full question During the immediate postpartum period after giving birth to twins, the client experiences uterine atony. What should the nurse do first? You Selected: • Gently massage the fundus. Correct response: • Gently massage the fundus. Explanation: Remediation: Question 5 See full question The nurse has provided health teaching about physiologic changes that can be expected during the postpartum period to a postpartum client who is bottle-feeding her neonate. Which client statement indicates that this teaching has been effective? You Selected: • “My menstrual flow should resume in approximately 6 to 10 weeks." Correct response: • “My menstrual flow should resume in approximately 6 to 10 weeks." Explanation: Question 6 See full question The nurse makes a home visit to a primigravida on the fourth postpartum day after birth of a viable neonate. When the nurse enters the house, the nurse finds the client sitting in a chair, crying inconsolably, while the neonate is crying in another room. The client tells the nurse that she has not been sleeping well and has been hearing voices. The nurse determines that the client is most likely experiencing: You Selected: • postpartum psychosis. Correct response: • postpartum psychosis. Explanation: Remediation: Question 7 See full question Four hours after cesarean birth of a neonate weighing 8 lb, 13 oz (4,000 g), the primiparous client asks, “If I get pregnant again, will I need to have a cesarean?” When responding to the client, the nurse should base the response to the client about vaginal birth after cesarean (VBAC) on which standard of practice? You Selected: • A history of rapid labor is a necessary criterion for VBAC. Correct response: • VBAC may be possible if the client has not had a classic uterine incision. Explanation: Remediation: Question 8 See full question A primiparous client 3 days postpartum is to be discharged on heparin therapy. After teaching her about possible adverse effects of heparin therapy, the nurse determines that the client needs further instruction when she states that the adverse effects include which symptom? You Selected: • bleeding gums Correct response: • slow pulse Explanation: Remediation: Question 9 See full question A diabetic postpartum client plans to breastfeed. The nurse determines that the client’s understanding of breastfeeding instructions is sufficient when she states: You Selected: • “Insulin will be transferred to the baby through breast milk.” Correct response: • “Breastfeeding will assist in lowering maternal blood glucose.” Explanation: Remediation: Question 2 See full question A primiparous client planning to breastfeed her term neonate born vaginally asks, “When will my ‘real’ milk come in?” The nurse explains to the client that after childbirth, breasts begin to produce milk within what time period? You Selected: • 2 to 4 days Correct response: • 2 to 4 days Explanation: Remediation: Question 3 See full question A primiparous client who is bottle-feeding her neonate asks, “When should I start giving the baby solid foods?” The nurse instructs the client to introduce solid foods no sooner than at which age? You Selected: • 6 months Correct response: • 6 months Explanation: Remediation: Question 4 See full question The nurse is caring for a postpartum client. Which of the following are appropriate nursing interventions for the prevention of a urinary tract infection (UTI)? Select all that apply. You Selected: • Collaborate with the physician or primary care provider for antibiotic therapy. Correct response: • Encourage the client to drink at least eight 8-ounce glasses of water daily. • Encourage the client to empty her bladder completely every 2-4 hours. Explanation: Question 5 See full question A client two days postpartum was given a shot of RhoGAM. At the postpartum home visit, the client asks the nurse why she needed RhoGAM. Which of the following is the most appropriate response by the nurse? You Selected: • “RhoGAM suppresses antibody formation in women with Rh negative blood after giving birth to an Rh positive baby.” Correct response: • “RhoGAM suppresses antibody formation in women with Rh negative blood after giving birth to an Rh positive baby.” Explanation: Remediation: Question 2 See full question A primiparous client planning to breastfeed her term neonate born vaginally asks, “When will my ‘real’ milk come in?” The nurse explains to the client that after childbirth, breasts begin to produce milk within what time period? You Selected: • 2 to 4 days Correct response: • 2 to 4 days Explanation: Remediation: Question 3 See full question A primiparous client who is bottle-feeding her neonate asks, “When should I start giving the baby solid foods?” The nurse instructs the client to introduce solid foods no sooner than at which age? You Selected: • 6 months Correct response: • 6 months Explanation: Remediation: Question 4 See full question The nurse is caring for a postpartum client. Which of the following are appropriate nursing interventions for the prevention of a urinary tract infection (UTI)? Select all that apply. You Selected: • Collaborate with the physician or primary care provider for antibiotic therapy. Correct response: • Encourage the client to drink at least eight 8-ounce glasses of water daily. • Encourage the client to empty her bladder completely every 2-4 hours. Explanation: Question 5 See full question A client two days postpartum was given a shot of RhoGAM. At the postpartum home visit, the client asks the nurse why she needed RhoGAM. Which of the following is the most appropriate response by the nurse? You Selected: • “RhoGAM suppresses antibody formation in women with Rh negative blood after giving birth to an Rh positive baby.” Correct response: • “RhoGAM suppresses antibody formation in women with Rh negative blood after giving birth to an Rh positive baby.” Explanation: Remediation: Question 10 See full question A client two days postpartum was given a shot of RhoGAM. At the postpartum home visit, the client asks the nurse why she needed RhoGAM. Which of the following is the most appropriate response by the nurse? You Selected: • “RhoGAM suppresses antibody formation in women with Rh positive blood after giving birth to an Rh negative baby.” Correct response: • “RhoGAM suppresses antibody formation in women with Rh negative blood after giving birth to an Rh positive baby.” Question 1 See full question Which practice should a nurse recommend to a client who has had a cesarean birth? You Selected: • Coughing and deep-breathing exercises Correct response: • Coughing and deep-breathing exercises Explanation: Remediation: Question 2 See full question A nurse visits a client at home on the 10th postpartum day. When assessing the client's uterus, which finding requires further evaluation? You Selected: • Minimal afterpains when nursing Correct response: • A fundus palpable at the umbilicus Explanation: Remediation: Question 3 See full question A client who gave birth to her first child 6 weeks ago seems overwhelmed by her new role as a mother. She tells the nurse, "I can't keep up with my housework any more because I spend so much time caring for the baby." The nurse should: You Selected: • help the client break down large tasks into smaller ones. Correct response: • help the client break down large tasks into smaller ones. Explanation: Remediation: Question 4 See full question Following a precipitous birth, examination of the client's vagina reveals a fourth-degree laceration. Which intervention is appropriate when caring for this client? You Selected: • Instructing the client to avoid using sitz baths if ordered Correct response: • Instructing the client about the importance of perineal (Kegel) exercises Explanation: Remediation: Question 5 See full question A primiparous client planning to breastfeed her term neonate born vaginally asks, “When will my ‘real’ milk come in?” The nurse explains to the client that after childbirth, breasts begin to produce milk within what time period? You Selected: • 24 hours Correct response: • 2 to 4 days Explanation: Remediation: Question 6 See full question During the immediate postpartum period, the nurse is caring for a primipara who gave birth to a postterm neonate after an oxytocin induction. When developing the client’s plan of care, which problem should the nurse expect to assess for frequently? You Selected: • increased pulse rate Correct response: • uterine atony Explanation: Remediation: Question 7 See full question Which client statement indicates effective teaching about burping a breastfed neonate? You Selected: • “When I switch to the other breast, I’ll burp the baby.” Correct response: • “When I switch to the other breast, I’ll burp the baby.” Explanation: Remediation: Question 8 See full question A breastfeeding primiparous client with a midline episiotomy is prescribed ibuprofen 200 mg orally. The nurse instructs the client to take the medication: You Selected: • immediately after a feeding. Correct response: • immediately after a feeding. Explanation: Question 9 See full question The community health nurse has a student nurse with him/her for the day. The RN asks the parents at the home visit if the student can be present for the breastfeeding assessment. The husband declines this opportunity. What is the nurse’s most appropriate response? You Selected: • Honor the father's preference. Correct response: • Honor the father's preference. Explanation: Remediation: Question 10 See full question Which of the following behaviors would indicate to the nurse that follow-up is needed for a client having difficulty attaching to her newborn? You Selected: • Lets the baby cry to get to sleep Correct response: • Lets the baby cry to get to sleep Question 1 See full question The nurse is caring for a primigravida who gave birth to a viable neonate 2 hours ago under epidural anesthesia. The new mother has a midline episiotomy. Which finding by the nurse would warrant further assessment? You Selected: • two perineal pads soaked with blood within 30 minutes Correct response: • two perineal pads soaked with blood within 30 minutes Explanation: Remediation: Question 2 See full question When teaching a primipara who gave birth to a term male neonate 1 hour ago about the characteristics of her neonate, what characteristic should the nurse include? You Selected: • kidneys typically nonpalpable Correct response: • obligatory nose breather Explanation: Remediation: Question 3 See full question A postpartum multiparous client diagnosed with endometritis is to receive intravenous antibiotic therapy with ampicillin. Before administering this drug, the nurse must take which action? You Selected: • Place the client in a side-lying position. Correct response: • Ask the client if she has any drug allergies. Explanation: Remediation: Question 4 See full question Which of the following behaviors would indicate to the nurse that follow-up is needed for a client having difficulty attaching to her newborn? You Selected: • Lets the baby cry to get to sleep Correct response: • Lets the baby cry to get to sleep Explanation: Remediation: Question 5 See full question A 2-day postpartum client tells the nurse that she is experiencing abdominal cramps whenever she breastfeeds her baby. Which of the following is the most appropriate response from the nurse? You Selected: • “Oxytocin is released when the baby sucks, which causes the uterus to contract.” Correct response: • “Oxytocin is released when the baby sucks, which causes the uterus to contract.” Explanation: Remediation: /.modal - - - - - - - - - - - - - - - - - - - - - - - - Footer - - - - - - - - - - - - - - - - - - - - - - - - - Question 1 See full question A nurse is preparing to perform a physical examination on a postpartum client. The client asks the nurse why gloves are necessary for the examination. What is the nurse's best response? You Selected: • "Gloves are required for standard precautions." Correct response: • "Gloves are required for standard precautions." Explanation: Remediation: On a client's first postpartum day, nursing assessment reveals vital signs within normal limits, a boggy uterus, and saturation of the perineal pad with lochia rubra. Which nursing intervention takes highest priority? You Selected: • Administering oxytocin as ordered Correct response: • Massaging the uterus gently Explanation: Remediation: Question 2 See full question A client has just given birth to her first child, a healthy, full-term girl. The client is Rho(D)-negative and her neonate is Rh-positive. What intervention will be performed to reduce the risk of Rh incompatibility? You Selected: • Injection of Rho(D) immune globulin to the mother during her 6 week follow-up visit Correct response: • Administration of Rho(D) immune globulin I.M. to the mother within 72 hours Explanation: Remediation: Question 3 See full question A nurse is teaching a client how to perform perineal care to reduce the risk of puerperal infection. Which activity indicates that the client understands proper perineal care? You Selected: • Spraying water from peri bottle into the vagina Correct response: • Using a peri bottle to clean the perineum after each voiding or bowel movement Explanation: Remediation: Question 4 See full question A primiparous client who is bottle-feeding her neonate asks, “When should I start giving the baby solid foods?” The nurse instructs the client to introduce solid foods no sooner than at which age? You Selected: • 10 months Correct response: • 6 months Explanation: Remediation: Question 5 See full question A client questions the nurse about the amount of her postpartum lochia flow. The client is 22 hours postpartum and is saturating a pad after 2 hours. Which of the following should the nurse do first? You Selected: • Begin a pad count and weigh each pad. Correct response: • Remind the client to drink fluids and rest between active periods. Explanation: Question 2 See full question A nurse is teaching a group of clients about birth control methods. When providing instruction about subdermal contraceptive implants, the nurse should cite which feature as the main advantage of this method? You Selected: • The implants provide effective, continuous contraception that isn't user dependent. Correct response: • The implants provide effective, continuous contraception that isn't user dependent. Explanation: Remediation: Question 3 See full question A nurse coming onto the night shift assesses a client who gave birth vaginally that morning. The nurse finds that the client's vaginal bleeding has saturated two perineal pads within 30 minutes. What is the first action the nurse should take? You Selected: • Call the physician for a methylergonovine order. Correct response: • Assess the fundus and massage it if it's boggy. Explanation: Remediation: Question 4 See full question A woman who is breastfeeding tells the nurse that she plans to return to work in 6 months and will probably wean her baby then. The client asks the nurse, “How will I stop producing milk when I want to wean the baby?” What information should the nurse give the client? You Selected: • gradual decrease in milk supply as the baby nurses less Correct response: • gradual decrease in milk supply as the baby nurses less Explanation: Remediation: Question 5 See full question Twenty-four hours after giving birth to a term neonate, a primipara receives acetaminophen with codeine for perineal pain. One hour after administering the medication, which finding should alert the nurse to the development of a possible side effect? You Selected: • dizziness Correct response: • dizziness Explanation: Question 6 See full question A client has admitted use of cocaine prior to beginning labor. After the infant is born, the nurse should anticipate the need to include which action in the infant’s plan of care? You Selected: • urine toxicology screening Correct response: • urine toxicology screening Explanation: Remediation: Question 7 See full question The nurse assigns an unlicensed assistive personnel (UAP) to care for a client who is 1 day postpartum. Which tasks would be appropriate to delegate to this person? Select all that apply. You Selected: • assisting the client with ambulation shortly after birth • changing the perineal pad and reporting the drainage • reinforcing good hygiene while assisting the client with washing the perineum Correct response: • changing the perineal pad and reporting the drainage • reinforcing good hygiene while assisting the client with washing the perineum • assisting the client with ambulation shortly after birth Explanation: Question 8 See full question After giving birth to a viable neonate 12 hours ago, the client’s fundus is firm at midline, and her breasts are soft. She has scant lochia and she is voiding sufficiently. The client reports pain in her lower back. What should the nurse do next? You Selected: • Administer a prescribed mild analgesic. Correct response: • Administer a prescribed mild analgesic. Explanation: Remediation: Question 9 See full question A 30-year-old multigravida with prolonged rupture of membranes is diagnosed with endometritis 36 hours after birth of a viable neonate. While assessing the client after intravenous antibiotic therapy is initiated, the nurse notes that the client’s temperature is 100° F (37.8° C), pulse rate is 124 bpm, and respirations are 24 breaths/minute. The nurse should: You Selected: • contact the primary care provider. Correct response: • contact the primary care provider. Explanation: Remediation: Question 10 See full question During a postpartum examination, the mother of a 2-week-old infant tearfully tells the nurse she feels very tired and thinks she is not a good mother to her baby. Which statement by the nurse would be best? You Selected: • "I am concerned about what you are experiencing. Tell me more about what you are thinking and feeling." Correct response: • "I am concerned about what you are experiencing. Tell me more about what you are thinking and feeling." Question 1 See full question Which measure included in the care plan for a client in the fourth stage of labor requires revision? You Selected: • Obtain an order for catheterization to protect the bladder from trauma. Correct response: • Obtain an order for catheterization to protect the bladder from trauma. Explanation: Remediation: Question 2 See full question A client whose blood type is A− gives birth to a neonate whose blood type is A+. The client is scheduled to have Rho(D) immune globulin administered. Before administering the medication, which action by the nurse is most important? You Selected: • Ensuring that the client understands the procedure and signs a consent for the vaccination Correct response: • Ensuring that the client understands the procedure and signs a consent for the vaccination Explanation: Remediation: Question 3 See full question A client tells a nurse that she's going to breast-feed her neonate, but she isn't sure what she should eat. Which client statement requires further teaching? You Selected: • "I'll take all the same medications I was taking before my pregnancy." Correct response: • "I'll take all the same medications I was taking before my pregnancy." Explanation: Remediation: Question 4 See full question A client is 24 hours postpartum. The nurse anticipates that the client's body is returning to homeostasis. Which assessment finding requires immediate intervention? You Selected: • Elevated temperature Correct response: • Positive Homans' sign Explanation: Remediation: Question 5 See full question A primiparous client, who has just given birth to a healthy term neonate after 12 hours of labor, holds and looks at her neonate and begins to cry. The nurse interprets this behavior as a sign of which response? You Selected: • a normal response to the birth Correct response: • a normal response to the birth Explanation: Remediation: Question 6 See full question A primiparous client who is breastfeeding develops endometritis on the third postpartum day. What instructions should the nurse give to the mother? You Selected: • The condition typically is treated with IV antibiotic therapy. Correct response: • The condition typically is treated with IV antibiotic therapy. Explanation: Remediation: Question 7 See full question On a client's second postpartum visit, a physician reviews the chart. What's the best term for the lochia described? You Selected: • Serosa Correct response: • Rubra Explanation: Remediation: Question 8 See full question A primiparous client who was diagnosed with hydramnios and breech presentation while in early labor is diagnosed with early postpartum hemorrhage at 1 hour after a cesarean birth. The client asks, “Why am I bleeding so much?” The nurse responds based on the understanding that the most likely cause of uterine atony in this client is which factor? You Selected: • lengthy and prolonged second stage of labor Correct response: • overdistention of the uterus from hydramnios Explanation: Remediation: Question 9 See full question A client two days postpartum was given a shot of RhoGAM. At the postpartum home visit, the client asks the nurse why she needed RhoGAM. Which of the following is the most appropriate response by the nurse? You Selected: • “RhoGAM suppresses antibody formation in women with Rh negative blood after giving birth to an Rh positive baby.” Correct response: • “RhoGAM suppresses antibody formation in women with Rh negative blood after giving birth to an Rh positive baby.” Explanation: Remediation: Question 10 See full question The nurse is teaching a new parent about the feeding patterns of a newborn infant. Which of the following statements by the parent would the nurse recognize as the correct description of a feeding pattern for a formula-fed infant? You Selected: • “Formula-fed infants usually feed every 3 to 4 hours.” Correct response: • “Formula-fed infants usually feed every 3 to 4 hours.” Question 1 See full question A nurse encourages a postpartum client to discuss the childbirth experience. Which client outcome is most appropriate for this client? You Selected: • "The client demonstrates the ability to integrate the childbirth experience and progress to the task of maternal role attainment." Correct response: • "The client demonstrates the ability to integrate the childbirth experience and progress to the task of maternal role attainment." Explanation: Remediation: Question 2 See full question A nurse is providing teaching to a client who's being discharged after delivering a hydatidiform mole. Which expected outcome takes highest priority for this client? You Selected: • "Client will schedule her first follow-up Papanicolaou (Pap) test and gynecologic examination for 6 months after discharge." Correct response: • "Client will use a reliable contraceptive method until her follow-up care is complete in 1 year and her hCG level is negative." Explanation: Remediation: Question 3 See full question In the fourth stage of labor, a full bladder increases the risk of what postpartum complication? You Selected: • Hemorrhage Correct response: • Hemorrhage Explanation: Remediation: Question 4 See full question At the beginning of the shift on the postpartum unit, a charge nurse notices that the licensed practical nurse (LPN) she's working with is acting inappropriately and smells of alcohol. When the charge nurse confronts the LPN, the LPN apologizes and promises that she'll never report to work in this condition again. Which step should the charge nurse take next? You Selected: • Notify the shift supervisor and rearrange the client care assignment. Correct response: • Notify the shift supervisor and rearrange the client care assignment. Explanation: Question 5 See full question A registered nurse is staff-shared to the maternal-neonatal unit where she has never worked before. How can this nurse be best employed? You Selected: • Assign her a client care assignment in the postpartum unit. Correct response: • Assign her a client care assignment in the postpartum unit. Explanation: Question 6 See full question After the first breastfeeding, the client asks the nurse, “How often should I try to breastfeed?” What frequency should the nurse recommend? You Selected: • every 2 to 3 hours for the first 48 hours Correct response: • every 2 to 3 hours for the first 48 hours Explanation: Remediation: Question 7 See full question While assisting a multiparous client to the bathroom for the first time 1 hour after a vaginal birth of a viable neonate, the nurse notes that the client’s urine has two small blood clots in the measuring container. What should the nurse do next? You Selected: • Document this observation as a normal finding. Correct response: • Document this observation as a normal finding. Explanation: Remediation: Question 8 See full question After instructing a primiparous client about episiotomy care, which client statement indicates successful teaching? You Selected: • “I wipe the area from front to back using a blotting motion." Correct response: • “I wipe the area from front to back using a blotting motion." Explanation: Remediation: Question 9 See full question Which measure would the nurse expect to include in the teaching plan for a multiparous client who gave birth 24 hours ago and is receiving intravenous antibiotic therapy for cystitis? You Selected: • emptying the bladder every 2 to 4 hours while awake Correct response: • emptying the bladder every 2 to 4 hours while awake Explanation: Remediation: Question 10 See full question During the second day postpartum, the nurse notices that a client is initiating breastfeeding with her infant and changing her infant's diapers with a little assistance from her partner. According to Reva Rubin's "phases of bonding," which of the following is the appropriate phase the woman is experiencing? You Selected: • The taking-in phase Correct response: • The taking-hold phase Question 1 See full question A postpartum client requires teaching about breast-feeding. Which client statement indicates understanding of how to prevent breast engorgement? You Selected: • "I will use an electric breast pump." Correct response: • "I will breast-feed as often as the infant is hungry — typically every 1 to 3 hours." Explanation: Remediation: Question 2 See full question A client takes a hormonal contraceptive to prevent pregnancy. The nurse should instruct her to use an alternative contraceptive method when receiving which drug concomitantly? You Selected: • Hydrocortisone Correct response: • Primidone Explanation: Remediation: Question 3 See full question During an annual checkup, a client tells the nurse that she and her partner have decided to start a family. Ideally, when should the nurse plan for childbirth education to begin and end? You Selected: • It should begin before conception and end 3 months after childbirth. Correct response: • It should begin before conception and end 3 months after childbirth. Explanation: Remediation: Question 4 See full question A client recently gave birth to a boy. Two minutes before breast-feeding the baby, she administers one nasal spray (40 units/ml) of oxytocin into each nostril. Why is the client using this drug? You Selected: • To stimulate lactation Correct response: • To stimulate lactation Explanation: Remediation: Question 5 See full question A nurse is caring for a client during the first postpartum day. The client asks the nurse how to relieve pain from her episiotomy. What should the nurse instruct the woman to do? You Selected: • Take a sitz bath. Correct response: • Apply an ice pack to her perineum. Explanation: Remediation: Question 6 See full question During a home visit to a primiparous client who gave birth vaginally 14 days ago, the client says, “I have been crying a lot the last few days. I just feel so awful. I am a rotten mother. I just do not have any energy. Plus, my husband just got laid off from his job.” The nurse observes that the client’s appearance is disheveled. What would be the nurse’s best response? You Selected: • “It is not unusual for some mothers to feel depressed after the birth of a baby. I think I should contact your health care provider.” Correct response: • “It is not unusual for some mothers to feel depressed after the birth of a baby. I think I should contact your health care provider.” Explanation: Remediation: Question 7 See full question A postpartum primiparous client is having difficulty breastfeeding her infant. The infant latches on to the breast, but the mother’s nipples are extremely sore during and after each feeding. The client needs further instruction about breastfeeding when she states: You Selected: • “The baby needs to have as much of the nipple and areola in his mouth as possible to prevent sore and cracked nipples.” Correct response: • “As long as some of my nipple is in the baby’s mouth, the baby will receive enough milk.” Explanation: Remediation: Question 8 See full question A nurse is walking down the hall in the main corridor of a hospital when the infant security alert system sounds and a code for an infant abduction is announced. The first responsibility of the nurse when this situation occurs is to take which action? You Selected: • Move to the entrance of the hospital and check each person leaving. Correct response: • Observe individuals in the area for large bags or oversized coats. Explanation: Remediation: Question 9 See full question A couple in the antenatal unit is not satisfied with the care they are receiving. They have spent the past 15 minutes expressing dissatisfaction to the nurse about the care the client is receiving today. What is the most appropriate response by the nurse? You Selected: • Encourage the family to identify their frustrations and fears. Correct response: • Encourage the family to identify their frustrations and fears. Explanation: Remediation: Question 10 See full question A nurse is caring for a postpartum client suspected of developing postpartum psychosis. Which statements accurately characterize this disorder? Select all that apply. You Selected: • Symptoms include delusions and hallucinations. • The disorder rarely occurs without a psychiatric history. • Suicide and infanticide are uncommon in this disorder. Correct response: • Symptoms include delusions and hallucinations. • The disorder rarely occurs without a psychiatric history. Question 1 See full question A client gives birth to a neonate prematurely at 28 weeks' gestation. The neonate is placed in the neonatal intensive care unit (NICU). Three days later, the neonate's father seems withdrawn and barely speaks to the staff when visiting his child in the NICU. Which interpretation of his behavior is most appropriate? You Selected: • The father has depression because of grieving. Correct response: • The father has depression because of grieving. Explanation: Remediation: Question 2 See full question A nurse brings a new mother her neonate for the first time approximately 1 hour after the neonate's birth. After checking the identification, the nurse hands the neonate to the mother. Within a few minutes, the mother begins to undress her baby. What should the nurse do? You Selected: • Encourage the mother to rewrap the baby because the room is cold. Correct response: • Anticipate and support the behavior as a normal part of bonding. Explanation: Remediation: Question 3 See full question Puerperium is defined as: You Selected: • the 6 weeks following birth. Correct response: • the 6 weeks following birth. Explanation: Question 4 See full question A nurse is caring for a 1-day postpartum mother who's very talkative but isn't confident in her decision- making skills. The nurse is aware that this is a normal phase for the mother. What is this phase called? You Selected: • Taking-over phase Correct response: • Taking-in phase Explanation: Remediation: Question 5 See full question A woman who has given birth to a healthy baby is being discharged. As a part of the discharge teaching, the nurse should instruct the client to observe vaginal discharge for postpartum hemorrhage and notify the healthcare provider (HCP) about: You Selected: • saturating a pad in an hour. Correct response: • saturating a pad in an hour. Explanation: Remediation: Question 6 See full question Rho (D) immune globulin (RhoGAM) is prescribed for a client before she is discharged after a spontaneous abortion. The nurse instructs the client that this drug is used to prevent which condition? You Selected: • development of Rh-positive antibodies Correct response: • development of Rh-positive antibodies Explanation: Question 7 See full question When assessing an 18-year-old primipara who gave birth to a viable neonate under epidural anesthesia 24 hours ago, the nurse determines that the fundus is firm but to the right of midline. Based on this finding, the nurse should further assesses for: You Selected: • urinary retention. Correct response: • urinary retention. Explanation: Remediation: Question 1 See full question In the fourth stage of labor, a full bladder increases the risk of what postpartum complication? You Selected: • Hemorrhage Correct response: • Hemorrhage Explanation: Remediation: Question 2 See full question A client and her boyfriend of 5 months are celebrating the birth of a healthy baby boy when the client's estranged partner arrives to visit the baby he believes is his son. The nurse caring for the client knows that the estranged partner has the right to: You Selected: • hold the neonate after the mother gives permission. Correct response: • hold the neonate after the mother gives permission. Explanation: Remediation: Question 3 See full question While caring for a multiparous client 4 hours after vaginal birth of a term neonate, the nurse notes that the mother’s temperature is 99.8°F (37.2°C), the pulse is 66 bpm, and the respirations are 18 breaths/min. Her fundus is firm, midline, and at the level of the umbilicus. The nurse should: You Selected: • continue to monitor the client’s vital signs. Correct response: • continue to monitor the client’s vital signs. Explanation: Remediation: Question 4 See full question A primiparous client is on a regular diet 24 hours postpartum. She is from Guatemala and speaks only Spanish. The client’s mother asks the nurse if she can bring her daughter some “special foods from home.” The nurse responds, based on the understanding about which principle? You Selected: • The mother can bring the daughter any foods that she desires. Correct response: • The mother can bring the daughter any foods that she desires. Explanation: Remediation: Question 5 See full question A nurse is giving a shift report about a client in labor. Which of the following information is the least important to include to complete the report at the change of shift? You Selected: • Cervical effacement, dilation, station. Correct response: • Bottle- or breastfeeding preference. Explanation: Remediation: /.modal - - - - - - - - - - - - - - - - - - - - - - - - Footer - - - - - - - - - - - - - - - - - - - - - - - - - Question 8 See full question A primiparous client is on a regular diet 24 hours postpartum. She is from Guatemala and speaks only Spanish. The client’s mother asks the nurse if she can bring her daughter some “special foods from home.” The nurse responds, based on the understanding about which principle? You Selected: • The mother can bring the daughter any foods that she desires. Correct response: • The mother can bring the daughter any foods that she desires. Explanation: Remediation: Question 9 See full question During a home visit to a breastfeeding primiparous client at 1 week postpartum, the client tells the nurse that her nipples have become sore and cracked from the feedings. Which instructions should the nurse give the client? You Selected: • Position the baby with the entire areola in the baby’s mouth. Correct response: • Position the baby with the entire areola in the baby’s mouth. Explanation: Remediation: Question 10 See full question A 30-year-old multigravida with prolonged rupture of membranes is diagnosed with endometritis 36 hours after birth of a viable neonate. While assessing the client after intravenous antibiotic therapy is initiated, the nurse notes that the client’s temperature is 100° F (37.8° C), pulse rate is 124 bpm, and respirations are 24 breaths/minute. The nurse should: You Selected: • contact the primary care provider. Correct response: • contact the primary care provider. Question 1 See full question As part of the postpartum follow-up, a 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 assessment would the nurse make? You Selected: • A home assessment is necessary to assure the well-being of the mother and the neonate. Correct response: • This is expected behavior for a client 3 to 7 days postpartum. Explanation: Remediation: Question 2 See full question Which measure included in the care plan for a client in the fourth stage of labor requires revision? You Selected: • Obtain an order for catheterization to protect the bladder from trauma. Correct response: • Obtain an order for catheterization to protect the bladder from trauma. Explanation: Remediation: Question 3 See full question Staff nurses on the postpartum floor are concerned that discharge teaching is consuming a large portion of their time. How can the nurses teach their clients in a more efficient manner? You Selected: • Conduct a class for clients who require the same discharge teaching. Correct response: • Conduct a class for clients who require the same discharge teaching. Explanation: Remediation: Question 4 See full question The nurse has been assigned to care for several postpartum clients and their neonates on a birthing unit. Which client should the nurse assess first? You Selected: • a primiparous client at 2 hours postpartum who gave birth to a term neonate vaginally Correct response: • a primiparous client at 2 hours postpartum who gave birth to a term neonate vaginally Explanation: Remediation: Question 5 See full question On a client's second postpartum visit, a physician reviews the chart. What's the best term for the lochia described? You Selected: • Rubra Correct response: • Rubra Explanation: Remediation: Question 6 See full question Three hours postpartum, a primiparous client’s fundus is firm and midline. On perineal inspection, the nurse observes a small, constant trickle of blood. Which condition should the nurse assess further? You Selected: • retained placental tissue Correct response: • perineal lacerations Explanation: Remediation: Question 7 See full question A nurse is giving a shift report about a client in labor. Which of the following information is the leastimportant to include to complete the report at the change of shift? You Selected: • Cervical effacement, dilation, station. Correct response: • Bottle- or breastfeeding preference. Explanation: Remediation: Question 8 See full question A nurse is caring for a 1-day postpartum client. The progress note below informs the nurse that the client is in which phase of the postpartum period? You Selected: • Taking hold. Correct response: • Taking in. Explanation: Remediation: Question 9 See full question The nurse is caring for a client in the newborn nursery. Which of the following are appropriate actions for the nurse to take that will help to prevent neonatal infection? Select all that apply. You Selected: • Good hand washing technique • Keeping the umbilical cord covered with sterile gauze • Isolation of infected infants with communicable disease Correct response: • Good hand washing technique • Isolation of infected infants with communicable disease • Hand sanitizer with points of contact Explanation: Remediation: Question 10 See full question A nurse completes the initial assessment of a newborn. According to the due date on the antenatal record, the baby is 12 days postmature. Which of the following physical findings contradicts the estimated gestational age of the newborn? You Selected: • Absence of lanugo Correct response: • Increased amounts of vernix Question 1 See full question On her third postpartum day, a client complains of chills and aches. Her chart shows that she has had a temperature of 100.6° F (38.1° C) for the past 2 days. The nurse assesses foul-smelling, yellow lochia. What should the nurse do next? You Selected: • Assess the client's breasts for engorgement. Correct response: • Anticipate that the physician will order laboratory tests and cultures. Explanation: Remediation: Question 2 See full question A primiparous client who is bottle-feeding her neonate at 12 hours after birth asks the nurse, “When will my menstrual cycle return?” Which response by the nurse would be most appropriate? You Selected: • “You can expect your menses to start in 12 to 14 weeks.” Correct response: • “It will probably be 6 to 10 weeks before it starts again.” Explanation: Question 3 See full question A client gave birth 2 days ago and has been given instructions on breast care for bottle-feeding mothers. Which statement indicates that the nurse should reinforce the instructions to the client? You Selected: • “When showering, I will direct water onto my shoulders.” Correct response: • “I will use a breast pump to remove any milk that may appear.” Explanation: Remediation: Question 4 See full question While assessing the fundus of a multiparous client 36 hours after delivery of a term neonate, the nurse notes a separation of the abdominal muscles. What action should the nurse take based on this assessment? You Selected: • Demonstrate exercises involving head and shoulder lifting. Correct response: • Discuss with the client that no further action is needed. Explanation: Remediation: Question 5 See full question A nurse completes the initial assessment of a newborn. According to the due date on the antenatal record, the baby is 12 days postmature. Which of the following physical findings contradicts the estimated gestational age of the newborn? You Selected: • Increased amounts of vernix Correct response: • Increased amounts of vernix Explanation: • Remediation: Question 1 See full question A nurse is preparing to perform a physical examination on a postpartum client. The client asks the nurse why gloves are necessary for the examination. What is the nurse's best response? You Selected: • "Gloves are required for standard precautions." Correct response: • "Gloves are required for standard precautions." Explanation: Remediation: Question 1 See full question A postpartum client requires teaching about breast- feeding. Which client statement indicates understanding of how to prevent breast engorgement? You Selected: • "I will breast-feed as often as the infant is hungry — typically every 1 to 3 hours." Correct response: • "I will breast-feed as often as the infant is hungry — typically every 1 to 3 hours." Explanation: Remediation: Question 2 See full question A nurse is preparing to perform a physical examination on a postpartum client. The client asks the nurse why gloves are necessary for the examination. What is the nurse's best response? You Selected: • "Gloves are required for standard precautions." Correct response: • "Gloves are required for standard precautions." Explanation: Remediation: Question 3 See full question During the first formula feeding, a client has difficulty getting her neonate to take the artificial nipple into the mouth. In assessing the problem, the nurse should intervene if the mother: You Selected: • strokes the neonate's lips gently with the nipple. Correct response: • pushes only the tip of the nipple into the neonate's mouth. Explanation: Remediation: Question 4 See full question A client is 9 days postpartum and breast-feeding her neonate. The client experiences pain, redness, and swelling of her left breast and is diagnosed with mastitis. The nurse teaching the client how to care for her infected breast should include which information? You Selected: • Use a warm moist compress over the painful area. Correct response: • Use a warm moist compress over the painful area. Explanation: Remediation: Question 5 See full question The nurse is providing the results of a community assessment to the nurse’s colleagues. Which of the following determinants of health does the nurse know is most influential on the outcomes of the postpartum families living within this community? You Selected: • Education and literacy Correct response: • Income and social status Explanation: /.modal - - - - - - - - - - - - - - - - - - - - - - - - Footer - - - - - - - - - - - - - - - - - - - - - - - - - Question 4 See full question A postpartum clinic nurse is assessing a client 4 weeks postpartum after a vaginal birth. Which of the following assessments would indicate to the nurse that the client is experiencing normal hemodynamic changes occurring in the postpartum period? You Selected: • There is an increase in cardiac output by 10%. Correct response: • The hematocrit rises from 34% to 40%. Explanation: Question 5 See full question The client is a 17-year-old single mother who has given birth. On her first postpartum day, the client seems overwhelmed with her new baby and asks the nurse how she is supposed to interact with her baby when all the baby does is eat and sleep. Which of the following actions would be most effective for the nurse to use to facilitate mother–infant attachment? You Selected: • Demonstrate different positions for holding the baby. Correct response: • Show the client how the baby initiates interaction with her and attends to her. Explanation: Question 3 See full question The nurse is providing follow-up care with a client 10 days after birth of a newborn. The nurse would anticipate what outcomes for the new mother? Select all that apply. You Selected: • The client feeds the baby every 6 to 8 hours without difficulty. Correct response: • The client feels tired but can care for herself and her new infant. • The family has adequate support from one another and others. • Lochia is changing from red to pink and is smaller in amount. • The client has positive comments about her new infant. Explanation: Remediation: Question 1 See full question In the maternal attachment process, which statement best describes the anticipated actions in the taking-hold phase? You Selected: • Kissing, embracing, and caring for the neonate Correct response: • Kissing, embracing, and caring for the neonate Explanation: Remediation: Question 2 See full question When preparing a multigravid client who has undergone evacuation of a hydatidiform mole for discharge, the nurse explains the need for follow-up care. The nurse determines that the client understands the instruction when she says that she is at risk for developing which problem? You Selected: • multifetal pregnancies Correct response: • choriocarcinoma Explanation: Remediation: Question 3 See full question The nurse has assisted a multigravida with a precipitous birth of a viable neonate. Because a precipitous birth can lead to decreased uterine tone, what nursing action should help to prevent this complication? You Selected: • Massage the client's fundus continuously. Correct response: • Encourage the mother to breastfeed the infant. Explanation: Remediation: Question 4 See full question The nurse is providing follow-up care with a client 10 days after birth of a newborn. The nurse would anticipate what outcomes for the new mother? Select all that apply. You Selected: • The client feels tired but can care for herself and her new infant. • The client has positive comments about her new infant. • The family has adequate support from one another and others. • Lochia is changing from red to pink and is smaller in amount. Correct response: • The client feels tired but can care for herself and her new infant. • The family has adequate support from one another and others. • Lochia is changing from red to pink and is smaller in amount. • The client has positive comments about her new infant. Explanation: Remediation: Question 1 See full question When assessing a postpartum client, the nurse notes a continuous flow of bright red blood from the vagina. The uterus is firm and no clots can be expressed. Which action should the nurse take? You Selected: • Notify the physician. Correct response: • Notify the physician. Explanation: Remediation: Question 2 See full question A client is asking to go to the bathroom 45 minutes after childbirth. She had an epidural for labor and birth, has an IV infusing, and every 15 minutes assessments are in progress. To provide the safest care for this client the nurse should: You Selected: • assess the client's ability to stand and bear weight before going to the bathroom. Correct response: • assess the client's ability to stand and bear weight before going to the bathroom. Explanation: Remediation: Question 3 See full question A primiparous client who gave vaginal birth 1 hour ago voices anxiety because she has a nephew with Down syndrome. After teaching the client about Down syndrome, which client statements indicate the need for additional teaching? You Selected: • “Down syndrome is an abnormality that can result from a missing chromosome.” Correct response: • “Down syndrome is an abnormality that can result from a missing chromosome.” Explanation: Remediation: Question 4 See full question The nurse assigns an unlicensed assistive personnel (UAP) to care for a client who is 1 day postpartum. Which tasks would be appropriate to delegate to this person? Select all that apply. You Selected: • assisting the client with ambulation shortly after birth • reinforcing good hygiene while assisting the client with washing the perineum • changing the perineal pad and reporting the drainage Correct response: • changing the perineal pad and reporting the drainage • reinforcing good hygiene while assisting the client with washing the perineum • assisting the client with ambulation shortly after birth Explanation: Question 5 See full question A 26-year-old primiparous client is seen in the urgent care clinic 2 weeks after giving birth to a viable female neonate. The client, who is breastfeeding, is diagnosed with infectious mastitis of the right breast. The client asks the nurse, “Can I continue breastfeeding?” The nurse should tell the client: You Selected: • “You can continue to breastfeed, feeding your baby more frequently.” Correct response: • “You can continue to breastfeed, feeding your baby more frequently.” Explanation: Remediation: Question 5 See full question A 26-year-old primiparous client is seen in the urgent care clinic 2 weeks after giving birth to a viable female neonate. The client, who is breastfeeding, is diagnosed with infectious mastitis of the right breast. The client asks the nurse, “Can I continue breastfeeding?” The nurse should tell the client: You Selected: • “You must stop breastfeeding because the breast is contaminated.” Correct response: • “You can continue to breastfeed, feeding your baby more frequently.” Explanation: Remediation: /.modal - - - - - - - - - - - - - - - - - - - - - - - - Footer - - - - - - - - - - - - - - - - - - - - - - - - - Question 4 See full question The nurse is reviewing discharge instructions with a postpartum breastfeeding client who is going home. She has chosen depot medroxyprogesterone acetate (DMPA) as birth control. Which statement by the client identifies that she needs further instruction concerning birth control? You Selected: • “You will give me my first DMPA inection before I leave today.” Correct response: • “You will give me my first DMPA inection before I leave today.” Explanation: Remediation: Question 5 See full question A primiparous client diagnosed with cystitis at 48 hours postpartum who is receiving intravenous ampicillin asks the nurse, “Can I still continue to breastfeed my baby?” The nurse should tell the client: You Selected: • "Alternate your breastfeeding with formula feeding to help you rest." Correct response: • "You can continue to breastfeed as long as you want to do so." Explanation: Remediation: Question 1 See full question A nurse is teaching a client how to use a diaphragm. Which statement about using a diaphragm is appropriate? You Selected: • "Remove the diaphragm immediately after intercourse." Correct response: • "Leave the diaphragm in place for at least 6 hours after intercourse." Explanation: Remediation: Question 2 See full question At which time should the nurse anticipate assisting a client to breastfeed her neonate? You Selected: • after the neonate's first period of reactivity Correct response: • during the neonate's first period of reactivity Explanation: Remediation: Question 3 See full question A nurse on the labor-and-birth unit transfers a primiparous client and her term neonate to the mother- baby unit 2 hours after the client gave vaginal birth to the neonate. Which information is a priority for the nurse to report to the nurse receiving the client on the mother- baby unit? You Selected: • firm fundus when gentle massage is used Correct response: • firm fundus when gentle massage is used Explanation: Remediation: Question 4 See full question A primiparous client who underwent a cesarean birth 30 minutes ago is to receive Rho(D) immune globulin (RhoGAM). The nurse should administer the medication within which time frame after birth? You Selected: • 72 hours Correct response: • 72 hours Explanation: Remediation: Question 5 See full question Which of the following interventions will help prevent a pulmonary embolus (PE) in a postpartum woman? Select all that apply. You Selected: • Encourage the client to increase fluid intake. Correct response: • Encourage the client to increase fluid intake. • Teach the client leg exercises she can do in bed. • Encourage the client to ambulate in the room. Explanation: Remediation: /.modal - - - - - - - - - - - - - - - - - - - - - - - - Footer - - - - - - - - - - - - - - - - - - - - - - - - - Question 2 See full question When assessing a postpartum client, the nurse notes a continuous flow of bright red blood from the vagina. The uterus is firm and no clots can be expressed. Which action should the nurse take? You Selected: • Notify the physician. Correct response: • Notify the physician. Explanation: Remediation: Question 3 See full question A primiparous client planning to breastfeed her term neonate born vaginally asks, “When will my ‘real’ milk come in?” The nurse explains to the client that after childbirth, breasts begin to produce milk within what time period? You Selected: • 2 to 4 days Correct response: • 2 to 4 days Explanation: Remediation: Question 4 See full question A woman who is breastfeeding tells the nurse that she plans to return to work in 6 months and will probably wean her baby then. The client asks the nurse, “How will I stop producing milk when I want to wean the baby?” What information should the nurse give the client? You Selected: • gradual decrease in milk supply as the baby nurses less Correct response: • gradual decrease in milk supply as the baby nurses less Explanation: Remediation: Question 5 See full question The nurse is caring for a primipara who gave birth to a viable neonate vaginally 12 hours ago. The client is diagnosed with class II heart disease. The nurse should instruct the client to: You Selected: • keep fluid intake to a minimum to avoid fluid overload. Correct response: • allow the nursing staff to assist her in baby care. Explanation: Remediation: Question 6 See full question A nurse is palpating the uterine fundus of a client who gave birth to a neonate 8 hours ago. Identify the area where the nurse should expect to feel the fundus. You Selected: • Your selection and the correct area, market by the green box. Explanation: Remediation: Question 7 See full question The nurse assesses a swollen ecchymosed area to the right of an episiotomy on a primiparous client 6 hours after a vaginal birth. The nurse should next: You Selected: • apply an ice pack to the perineal area. Correct response: • apply an ice pack to the perineal area. Explanation: Remediation: Question 8 See full question A primiparous client who gave birth vaginally 8 hours ago desires to take a shower. The nurse anticipates remaining nearby the client to assess for which problem? You Selected: • fainting Correct response: • fainting Explanation: Remediation: Question 9 See full question The nurse finds that a client who gave birth 3 hours ago has completely saturated a perineal pad within 15 minutes. Which of the following actions should the nurse take? Select all that apply. You Selected: • Begin an intravenous infusion of lactated Ringer's solution. • Assess the client's vital signs. • Palpate the client's fundus. Correct response: • Assess the client's vital signs. • Palpate the client's fundus. Explanation: Remediation: Question 10 See full question A client tells the nurse during a postpartum parenting class that she has switched her 6-month infant from formula to cow's milk to save money on the cost of formula. Which one of the following statements made by the nurse would be the best? You Selected: • “Cow’s milk can be safely given to an infant older than one year of age.” Correct response: • “Cow’s milk can be safely given to an infant older than one year of age.” Question 1 See full question Lochia normally progresses in which pattern? You Selected: • Rubra, serosa, alba Correct response: • Rubra, serosa, alba Explanation: Remediation: Question 2 See full question While caring for a the postpartum client who is receiving treatment with bed rest and intravenous heparin therapy for a deep vein thromobosis, the nurse should contact the client’s health care provider (HCP) immediately if the client exhibited which symptom? You Selected: • Dyspnea Correct response: • Dyspnea Explanation: Question 3 See full question After suction and evacuation of a complete hydatidiform mole, the 28-year-old multigravid client asks the nurse when she can become pregnant again. The nurse would advise the client not to become pregnant again for at least how long? You Selected: • 6 months Correct response: • 12 months Explanation: Remediation: Question 4 See full question The nurse is assessing a cesarean section client who gave birth 12 hours ago. Findings include a distended abdomen with faint bowel sounds × 1 quadrant, fundus firm at umbilicus, lochia scant, rubra, and pain rated 2 on a scale of 1 to 10. The IV and Foley catheter have been discontinued, and the client received medication 3 hours ago for pain. The client can have pain medication every 3 to 4 hours. The nurse should first: You Selected: • have the client use the incentive spirometry. Correct response: • ambulate the client from the bed to the hallway and back. Explanation: Remediation: Question 5 See full question The partner of a postpartum client asks the nurse what is wrong with his infant’s mother and why she isn’t more joyful about the birth of their child. Which of the following would be the most appropriate response by the nurse? You Selected: • “Do any family members suffer from depression?” Correct response: • “How many days has it been since she gave birth?” Explanation: Remediation: /.modal - - - - - - - - - - - - - - - - - - - - - - - - Footer - - - - - - - - - - - - - - - - - - - - - - - - - Remediation: Question 3 See full question Normal lochial findings in the first 24 hours after birth include: You Selected: • bright red blood. Correct response: • bright red blood. Explanation: Remediation: Question 4 See full question A client has just given birth to her first child, a healthy, full-term girl. The client is Rho(D)-negative and her neonate is Rh-positive. What intervention will be performed to reduce the risk of Rh incompatibility? You Selected: • Administration of Rho(D) immune globulin I.M. to the mother within 72 hours Correct response: • Administration of Rho(D) immune globulin I.M. to the mother within 72 hours Explanation: Remediation: Question 5 See full question The nurse assigns an unlicensed assistive personnel (UAP) to care for a client who is 1 day postpartum. Which tasks would be appropriate to delegate to this person? Select all that apply. You Selected: • assisting the client with ambulation shortly after birth • reinforcing good hygiene while assisting the client with washing the perineum • changing the perineal pad and reporting the drainage Correct response: • changing the perineal pad and reporting the drainage • reinforcing good hygiene while assisting the client with washing the perineum • assisting the client with ambulation shortly after birth Explanation: Question 6 See full question A client is at the end of her first postpartum day. The nurse is assessing the client's uterus. Which finding requires further evaluation? You Selected: • Fundus two fingerbreadths above the umbilicus Correct response: • Fundus two fingerbreadths above the umbilicus Explanation: Remediation: Question 7 See full question A nurse is caring for a client during the first postpartum day. The client asks the nurse how to relieve pain from her episiotomy. What should the nurse instruct the woman to do? You Selected: • Apply an ice pack to her perineum. Correct response: • Apply an ice pack to her perineum. Explanation: Remediation: Question 8 See full question A nurse is assessing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus? You Selected: • At the level of the umbilicus Correct response: • One fingerbreadth below the umbilicus Explanation: Remediation: Question 9 See full question A primiparous client, 20 hours after giving birth, asks the nurse about starting postpartum exercises. What instructions would be most appropriate to include in the plan of care? You Selected: • Flex the knees while supine, and then inhale deeply and exhale while contracting the abdominal muscles. Correct response: • Flex the knees while supine, and then inhale deeply and exhale while contracting the abdominal muscles. Explanation: Remediation: Question 10 See full question A postpartum client requires teaching about breast-feeding. Which client statement indicates understanding of how to prevent breast engorgement? You Selected: • "I will breast-feed as often as the infant is hungry — typically every 1 to 3 hours." Correct response: • "I will breast-feed as often as the infant is hungry — typically every 1 to 3 hours." Question 1 See full question During an annual checkup, a client tells the nurse that she and her partner have decided to start a family. Ideally, when should the nurse plan for childbirth education to begin and end? You Selected: • It should begin before conception and end 3 months after childbirth. Correct response: • It should begin before conception and end 3 months after childbirth. Explanation: Remediation: Question 2 See full question A primipara calls the birthing unit 3 days after a vaginal birth. She tells the nurse that she is bottle- feeding and her breasts are swollen and painful. Which instructions would be appropriate? You Selected: • Use ice packs for 20 minutes every 3 to 4 hours. Correct response: • Use ice packs for 20 minutes every 3 to 4 hours. Explanation: Remediation: Question 3 See full question A new primiparous client asks the nurse, “Can my baby see?” Which statement about neonatal vision should the nurse include in the explanation? You Selected: • They can see objects up to 12 inches (30.5 cm) away. Correct response: • They can see objects up to 12 inches (30.5 cm) away. Explanation: Remediation: Question 4 See full question A 15-year-old unmarried primiparous client is being cared for in the hospital’s birthing center after vaginal birth of a viable neonate. The neonate is being placed for adoption through a social service agency. Four hours postpartum, the client asks if she can feed her baby. Which response would be most appropriate? You Selected: • “I will bring the baby to you for feeding.” Correct response: • “I will bring the baby to you for feeding.” Explanation: Remediation: Question 5 See full question A breastfeeding primiparous client with a midline episiotomy is prescribed ibuprofen 200 mg orally. The nurse instructs the client to take the medication: You Selected: • immediately after a feeding. Correct response: • immediately after a feeding. Explanation: Question 6 See full question The community health nurse is providing education to a client who has given birth 74 hours earlier. The nurse teaches the client that which of the following would be a late sign or symptom of hemorrhage? You Selected: • Peripad soaked over the course of 1 hour Correct response: • Peripad soaked over the course of 1 hour Explanation: Remediation: Question 7 See full question A postpartum client tells the nurse that she and her husband had an argument about continuing breastfeeding before he left for work in the morning. He was up all night, not able to sleep with the baby crying, and he wants the client to give the baby formula. What is the most appropriate immediate response from the nurse? You Selected: • “What are your feelings about breastfeeding?” Correct response: • “What are your feelings about breastfeeding?” Explanation: Remediation: Question 8 See full question A nurse and a nursing student drive to the home of a client with postpartum depression and discover the client and her baby completely naked in the backyard. The client is unable to communicate in an effective manner. What is the nurse’s most appropriate response to resolve this situation? You Selected: • Contact the nursing supervisor to clarify the appropriate actions in this acute mental health situation. Correct response: • Contact the nursing supervisor to clarify the appropriate actions in this acute mental health situation. Explanation: Remediation: Question 1 See full question As she tries to decide on a birth control method, a client requests information about medroxyprogesterone. Which statement represents the nurse's best response? You Selected: • Medroxyprogesterone needs to be administered every 12 weeks. Correct response: • Medroxyprogesterone needs to be administered every 12 weeks. Explanation: Remediation: Question 2 See full question Which information would the nurse include in the primiparous client’s discharge teaching plan about measures to provide visual stimulation for the neonate? You Selected: • Use brightly colored animals and cartoon figures on the wall. Correct response: • Maintain eye contact while talking to the baby. Explanation: Remediation: Question 3 See full question A primiparous client who gave vaginal birth 1 hour ago voices anxiety because she has a nephew with Down syndrome. After teaching the client about Down syndrome, which client statements indicate the need for additional teaching? You Selected: • “Older mothers are more likely to have a baby with chromosomal abnormalities.” Correct response: • “Down syndrome is an abnormality that can result from a missing chromosome.” Explanation: Remediation: Question 4 See full question A primiparous client diagnosed with cystitis at 48 hours postpartum who is receiving intravenous ampicillin asks the nurse, “Can I still continue to breastfeed my baby?” The nurse should tell the client: You Selected: • "You can continue to breastfeed as long as you want to do so." Correct response: • "You can continue to breastfeed as long as you want to do so." Explanation: Remediation: Question 5 See full question A postpartum client has a nursing diagnosis of risk for impaired urinary elimination related to loss of bladder sensation after childbirth. Which of the following priorities outcome criteria should the client achieve? You Selected: • Client voids more than 30 mL/hour without urinary retention beginning 1 hour after birth. Correct response: • Client voids more than 30 mL/hour without urinary retention beginning 1 hour after birth. Explanation: Remediation: Question 1 See full question The nurse has assisted a multigravida with a precipitous birth of a viable neonate. Because a precipitous birth can lead to decreased uterine tone, what nursing action should help to prevent this complication? You Selected: • Encourage the mother to breastfeed the infant. Correct response: • Encourage the mother to breastfeed the infant. Explanation: Remediation: Question 2 See full question While the nurse is preparing to assist the primiparous client to the bathroom to void 6 hours after a vaginal birth under epidural anesthesia, the client says that she feels dizzy when sitting up on the side of the bed. The nurse explains that this is most likely caused by which factor? You Selected: • effects of analgesics used during labor Correct response: • decreased blood volume in the vascular system Explanation: Remediation: Question 3 See full question The nurse assigns an unlicensed assistive personnel (UAP) to care for a client who is 1 day postpartum. Which tasks would be appropriate to delegate to this person? Select all that apply. You Selected: • assisting the client with ambulation shortly after birth • reinforcing good hygiene while assisting the client with washing the perineum • changing the perineal pad and reporting the drainage Correct response: • changing the perineal pad and reporting the drainage • reinforcing good hygiene while assisting the client with washing the perineum • assisting the client with ambulation shortly after birth Explanation: Question 4 See full question A breastfeeding client is seen at home by the visiting nurse 10 days after a vaginal birth. The client is reporting a warm, red, painful breast, a temperature of 100° F (37.7°C), and flulike symptoms. What should the nurse do? You Selected: • Inform the client that she needs to discontinue breastfeeding. Correct response: • Refer the woman to her health care provider (HCP). Explanation: Question 5 See full question A breastfeeding primiparous client asks the nurse how breast milk differs from cow’s milk. The nurse responds by saying that breast milk is higher in which nutrient? You Selected: • sodium Correct response: • fat Explanation: Remediation: /.modal - - - - - - - - - - - - - - - - - - - - - - - - Footer - - - - - - - - - - - - - - - - - - - - - - - - - Question 9 See full question A couple in the antenatal unit is not satisfied with the care they are receiving. They have spent the past 15 minutes expressing dissatisfaction to the nurse about the care the client is receiving today. What is the most appropriate response by the nurse? You Selected: • Encourage the family to identify their frustrations and fears. Correct response: • Encourage the family to identify their frustrations and fears. Explanation: Remediation: Question 10 See full question A postpartum client has a nursing diagnosis of risk for impaired urinary elimination related to loss of bladder sensation after childbirth. Which of the following priorities outcome criteria should the client achieve? You Selected: • The client will state that she has no discomfort with urinary elimination. Correct response: • Client voids more than 30 mL/hour without urinary retention beginning 1 hour after birth. Question 1 See full question A postpartum client is ready for discharge. Which client statement reflects an understanding of the teaching session? You Selected: • "I will call my physician if I notice redness, warmth, and pain in my breasts." Correct response: • "I will call my physician if I notice redness, warmth, and pain in my breasts." Explanation: Remediation: Question 2 See full question Staff nurses on the postpartum floor are concerned that discharge teaching is consuming a large portion of their time. How can the nurses teach their clients in a more efficient manner? You Selected: • Conduct a class for clients who require the same discharge teaching. Correct response: • Conduct a class for clients who require the same discharge teaching. Explanation: Remediation: Question 3 See full question Following a cesarean birth for abruptio placentae, a multigravid client tells the nurse, "I feel like such a failure. None of my other childbirths were like this." Which factor is most important for the nurse to consider when responding to the client? You Selected: • The client will most likely have postpartum blues. Correct response: • The client's feeling of grief is a normal reaction. Explanation: Remediation: Question 4 See full question A client has just had a cesarean section for a prolapsed cord. In reviewing the client's history, which factors places a client at risk for cord prolapse? Select all that apply. You Selected: • rupture of membranes • breech presentation • low lying placenta Correct response: • negative 2 station • low birthweight infant • rupture of membranes • breech presentation Explanation: Remediation: Question 5 See full question A woman who has given birth to a healthy baby is being discharged. As a part of the discharge teaching, the nurse should instruct the client to observe vaginal discharge for postpartum hemorrhage and notify the healthcare provider (HCP) about: You Selected: • saturating a pad in an hour. Correct response: • saturating a pad in an hour. Explanation: Remediation: Question 6 See full question In response to the nurse’s question about how she is feeling, a postpartum client states that she is fine. She then begins talking to the baby, checking the diaper, and asking infant care questions. The nurse determines the client is in which postpartal phase of psychological adaptation? You Selected: • taking hold Correct response: • taking hold Explanation: Remediation: Question 7 See full question After the nurse counsels a primiparous, breastfeeding client about diet and nutritional needs during the lactation period, which client statement indicates a need for additional teaching? You Selected: • “I should drink at least five glasses of fluid daily.” Correct response: • “I should drink at least five glasses of fluid daily.” Explanation: Remediation: Question 8 See full question Two weeks after a breastfeeding primiparous client is discharged, she calls the birthing center and says that she is afraid she is “losing my breast milk. The baby had been nursing every 4 hours, but now she is crying to be fed every 2 hours.” The nurse interprets the neonate’s behavior as most likely caused by which factor? You Selected: • the neonate’s temporary growth spurt, which requires more feedings Correct response: • the neonate’s temporary growth spurt, which requires more feedings Explanation: Remediation: Question 9 See full question A nurse is walking down the hall in the main corridor of a hospital when the infant security alert system sounds and a code for an infant abduction is announced. The first responsibility of the nurse when this situation occurs is to take which action? You Selected: • Observe individuals in the area for large bags or oversized coats. Correct response: • Observe individuals in the area for large bags or oversized coats. Explanation: Remediation: Question 1 See full question When caring for a client who has had a cesarean birth, which action by a nurse requires intervention? You Selected: • Monitoring pain status and providing necessary relief Correct response: • Removing the initial dressing for incision inspection Explanation: Remediation: Question 2 See full question A nurse is providing discharge teaching to a postpartum client. Which instruction is the priority to include in her teaching? You Selected: • "The neonate can sleep in the bed with you." Correct response: • "If you have excessive vaginal bleeding, massage your fundus and call the physician." Explanation: Remediation: Question 3 See full question In which phase of postpartal psychological adaption would discharge teaching regarding infant care most likely be successful? You Selected: • taking hold Correct response: • taking hold Explanation: Remediation: Question 4 See full question While observing a new mother interact with her first baby, the nurse observes that the client appears hesitant to care for the neonate. Which action would be most important for the nurse to do? You Selected: • Make a referral to the medical social worker. Correct response: • Continue to provide praise and support to the client. Explanation: Remediation: Question 5 See full question The nurse is caring for a postpartum client and suspects that the client has developed a postpartum adjustment reaction with depressed mood, also known as the “baby blues.” Which of the following client findings support the nurse’s assessment? Select all that apply. You Selected: • Expresses anxiety about caring for the newborn after discharge • Is tearful without an identifiable reason • Presence of fatigue and physical discomfort Correct response: • Is tearful without an identifiable reason • Expresses anxiety about caring for the newborn after discharge • Presence of fatigue and physical discomfort Explanation: Remediation: Question 1 See full question A registered nurse is staff-shared to the maternal- neonatal unit where she has never worked before. How can this nurse be best employed? You Selected: • Assign her a client care assignment in the postpartum unit. Correct response: • Assign her a client care assignment in the postpartum unit. Explanation: Question 2 See full question Which information would the nurse include in the primiparous client’s discharge teaching plan about measures to provide visual stimulation for the neonate? You Selected: • Maintain eye contact while talking to the baby. Correct response: • Maintain eye contact while talking to the baby. Explanation: Remediation: Question 3 See full question A multiparous client at 24 hours postpartum is found to have a swelling and pain in her right leg. She demonstrates a positive Homan sign with discomfort. The nurse should: You Selected: • ask the client to ambulate around the room Correct response: • notify the client’s health care provider (HCP) immediately Explanation: Remediation: Question 4 See full question A breastfeeding primiparous client who gave birth 8 hours ago asks the nurse, “How will I know that my baby is getting enough to eat?” Which guideline should the nurse include in the teaching plan as evidence of adequate intake? You Selected: • regain of lost birth weight by the third day Correct response: • six to eight wet diapers by the fifth day Explanation: Remediation: Question 5 See full question The nurse is caring for a postpartum client and suspects that the client has developed a postpartum adjustment reaction with depressed mood, also known as the “baby blues.” Which of the following client findings support the nurse’s assessment? Select all that apply. You Selected: • Presence of fatigue and physical discomfort • Is tearful without an identifiable reason • Expresses anxiety about caring for the newborn after discharge Correct response: • Is tearful without an identifiable reason • Expresses anxiety about caring for the newborn after discharge • Presence of fatigue and physical discomfort Explanation: Remediation: /.modal - - - - - - - - - - - - - - - - - - - - - - - - Footer - - - - - - - - - - - - - - - - - - - - - - - - - Question 10 See full question The nurse is caring for a postpartum client and suspects that the client has developed a postpartum adjustment reaction with depressed mood, also known as the “baby blues.” Which of the following client findings support the nurse’s assessment? Select all that apply. You Selected: • Presence of fatigue and physical discomfort • Is tearful without an identifiable reason Correct response: • Is tearful without an identifiable reason • Expresses anxiety about caring for the newborn after discharge • Presence of fatigue and physical discomfort