1. A postpartum nurse is preparing to care for a woman who has just delivered a healthy newborn infant. In the immediate postpartum period the nurse plans to take the woman's vital signs:
1. Every 30 minutes during the first hour and then every hour for the next two hours.
2. Every 15 minutes during the first hour and then every 30 minutes for the next two hours.
3. Every hour for the first 2 hours and then every 4 hours
4. Every 5 minutes for the first 30 minutes and then every hour for the next 4 hours.
2. A postpartum nurse is taking the vital signs of a woman who delivered a healthy newborn infant 4 hours ago. The nurse notes that the mother's temperature is 100.2*F. Which of the following actions would be most appropriate?
1. Retake the temperature in 15 minutes
2. Notify the physician
3. Document the findings
4. Increase hydration by encouraging oral fluids
3. The nurse is assessing a client who is 6 hours PP after delivering a full-term healthy infant. The client complains to the nurse of feelings of faintness and dizziness. Which of the following nursing actions would be most appropriate?
1.Obtain hemoglobin and hematocrit levels
2.Instruct the mother to request help when getting out of bed
3.Elevate the mother's legs
4.Inform the nursery room nurse to avoid bringing the newborn infant to the mother until the feelings of light-headedness and dizziness have subsided.
4. A nurse is preparing to perform a fundal assessment on a postpartum client. The initial nursing action in performing this assessment is which of the following?
1. Ask the client to turn on her side
2. Ask the client to lie flat on her back with the knees and legs flat and straight.
3. Ask the mother to urinate and empty her bladder
4. Massage the fundus gently before determining the level of the fundus.
5. The nurse is assessing the lochia on a 1 day PP patient. The nurse notes that the lochia is red and has a foul-smelling odor. The nurse determines that this assessment finding is:
2.Indicates the presence of infection
3.Indicates the need for increasing oral fluids
4.Indicates the need for increasing ambulation
6. When performing a PP assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which of the following nursing actions is most appropriate?
1. Document the findings
2. Notify the physician
3. Reassess the client in 2 hours
4. Encourage increased intake of fluids.
7. A nurse in a PP unit is instructing a mother regarding lochia and the amount of expected lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never exceed the need for:
1. One peripad per day
2. Two peripads per day
3. Three peripads per day
4. Eight peripads per day
8. A PP nurse is providing instructions to a woman after delivery of a healthy newborn infant. The nurse instructs the mother that she should expect normal bowel elimination to return:
1. On the day of the delivery
2. 3 days PP
3. 7 days PP
4. within 2 weeks PP
9. Select all of the physiological maternal changes that occur during the PP period.
1.Cervical involution ceases immediately
2.Vaginal distention decreases slowly
3.Fundus begins to descend into the pelvis after 24 hours
4.Cardiac output decreases with resultant tachycardia in the first 24 hours
5.Digestive processes slow immediately.
10. A nurse is caring for a PP woman who has received epidural anesthesia and is monitoring the woman for the presence of a vulva hematoma. Which of the following assessment findings would best indicate the presence of a hematoma?
1.Complaints of a tearing sensation
2.Complaints of intense pain
3.Changes in vital signs
4.Signs of heavy bruising
11. A nurse is developing a plan of care for a PP woman with a small vulvar hematoma. The nurse includes which specific intervention in the plan during the first 12 hours following the delivery of this client?
1.Assess vital signs every 4 hours
2.Inform health care provider of assessment findings
3.Measure fundal height every 4 hours
4.Prepare an ice pack for application to the area.
12. A new mother received epidural anesthesia during labor and had a forceps delivery after pushing 2 hours. At 6 hours PP, her systolic blood pressure has dropped 20 points, her diastolic BP has dropped 10 points, and her pulse is 120 beats per minute. The client is anxious and restless. On further assessment, a vulvar hematoma is verified. After notifying the health care provider, the nurse immediately plans to:
1. Monitor fundal height
2. Apply perineal pressure
3. Prepare the client for surgery.
4. Reassure the client
13. A nurse is monitoring a new mother in the PP period for signs of hemorrhage. Which of the following signs, if noted in the mother, would be an early sign of excessive blood loss?
1. A temperature of 100.4*F
2. An increase in the pulse from 88 to 102 BPM
3. An increase in the respiratory rate from 18 to 22 breaths per minute
4. A blood pressure change from 130/88 to 124/80 mm Hg
14. A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. When the nurse locates the fundus, she notes that the uterus feels soft and boggy. Which of the following nursing interventions would be most appropriate initially?
1. Massage the fundus until it is firm
2. Elevate the mothers legs
3. Push on the uterus to assist in expressing clots
4. Encourage the mother to void
15. A PP nurse is assessing a mother who delivered a healthy newborn infant by C-section. The nurse is assessing for signs and symptoms of superficial venous thrombosis. Which of the following signs or symptoms would the nurse note if superficial venous thrombosis were present?
1. Paleness of the calf area
2. Enlarged, hardened veins
3. Coolness of the calf area
4. Palpable dorsalis pedis pulses
16. A nurse is providing instructions to a mother who has been diagnosed with mastitis. Which of the following statements if made by the mother indicates a need for further teaching?
1. "I need to take antibiotics, and I should begin to feel better in 24-48 hours."
2. "I can use analgesics to assist in alleviating some of the discomfort."
3. "I need to wear a supportive bra to relieve the discomfort."
4. "I need to stop breastfeeding until this condition resolves."
17. A PP client is being treated for DVT. The nurse understands that the client's response to treatment will be evaluated by regularly assessing the client for:
1. Dysuria, ecchymosis, and vertigo
2. Epistaxis, hematuria, and dysuria
3. Hematuria, ecchymosis, and epistaxis
4. Hematuria, ecchymosis, and vertigo
18. A nurse performs an assessment on a client who is 4 hours PP. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. The nurse prepares immediately to:
1. Assess for hypovolemia and notify the health care provider
2. Begin hourly pad counts and reassure the client
3. Begin fundal massage and start oxygen by mask
4. Elevate the head of the bed and assess vital signs
19. A nurse is assessing a client in the 4th stage if labor and notes that the fundus is firm but that bleeding is excessive. The initial nursing action would be which of the following?
1. Massage the fundus
2. Place the mother in the Trendelenburg's position
3. Notify the physician
4. Record the findings
20. A nurse is caring for a PP client with a diagnosis of DVT who is receiving a continuous intravenous infusion of heparin sodium. Which of the following laboratory results will the nurse specifically review to determine if an effective and appropriate dose of the heparin is being delivered?
1. Prothrombin time
2. Internationalized normalized ratio
3. Activated partial thromboplastin time
4. Platelet count
21. A nurse is preparing a list of self-care instructions for a PP client who was diagnosed with mastitis. Select all instructions that would be included on the list.
1. Take the prescribed antibiotics until the soreness subsides.
2. Wear supportive bra
3. Avoid decompression of the breasts by breastfeeding or breast pump
4. Rest during the acute phase
5. Continue to breastfeed if the breasts are not too sore.
22. Methergine or pitocin is prescribed for a woman to treat PP hemorrhage. Before administration of these medications, the priority nursing assessment is to check the:
1. Amount of lochia
2. Blood pressure
3. Deep tendon reflexes
4. Uterine tone
23. Methergine or pitocin are prescribed for a client with PP hemorrhage. Before administering the medication(s), the nurse contacts the health provider who prescribed the medication(s) in which of the following conditions is documented in the client's medical history?
1. Peripheral vascular disease
4. Type 1 diabetes
24. Which of the following factors might result in a decreased supply of breast milk in a PP mother?
1. Supplemental feedings with formula
2. Maternal diet high in vitamin C
3. An alcoholic drink
4. Frequent feedings
25. Which of the following interventions would be helpful to a breastfeeding mother who is experiencing engorged breasts?
1. Applying ice
2. Applying a breast binder
3. Teaching how to express her breasts in a warm shower
4. Administering bromocriptine (Parlodel)
26. On completing a fundal assessment, the nurse notes the fundus is situated on the client's left abdomen. Which of the following actions is appropriate?
1. Ask the client to empty her bladder
2. Straight catheterize the client immediately
3. Call the client's health provider for direction
4. Straight catheterize the client for half of her uterine volume
27. The nurse is about the give a Type 2 diabetic her insulin before breakfast on her first day postpartum. Which of the following answers best describes insulin requirements im