NR327 - Quiz 4 - Postpartum NCLEX-Style Questions For Quiz 4 - July 2019

NR327 - Quiz 4 - Postpartum NCLEX-Style Questions (For Quiz 4) - July 2019

Source Of Questions For This Quiz: Saunders Comprehensive Review - NCLEX-RN Exam

Topics For This Quiz:

Postpartum Physiologic Adaptations Postpartum Psychosocial Adaptations Postpartum Complications Assessment of the Normal Newborn Care of the Normal Newborn

Postpartum NCLEX Material: https://quizlet.com/28890579/nclex-postpartum-flash-cards/

Newborn NCLEX Material in Quizlets:

1. https://quizlet.com/28890846/post-partumnewborn-flash-cards/

2. https://quizlet.com/214168825/ati-maternity-2-flash-cards/

Postpartum Physiological/Psychosocial Adaptations & Postpartum Complications NCLEX-Style

Questions (For Quiz 4):

• A nurse is performing a fundal assessment for a client who is 2 days postpartum and observes

the perineal pad for lochia. she notes the pad to be saturated approximately 12 cm with lochia that is bright red and contains small clots. Which of the following findings should the nurse document?

• Moderate lochia rubra
• Excessive blood loss
• Light lochia rubra
• Scant lochia serosa

Rationale:

• CORRECT: The client has moderate lochia rubra containing small clots, which is an expected

finding for the second day postpartum.

• Excessive blood loss is saturation of a perineal pad in 15 min or less or pooling of blood under

the client's buttocks.

• Light lochia rubra is a perineal pad that is saturated less than 10 cm with lochia.
• Scant lochia serosa (less than 2.5 cm on perineal pad) is pinkish brown in color and

serosanguineous in consistency. it occurs on day 4 to 12 following delivery."

• During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood

that soon stops. on assessment, a nurse finds the uterus to be firm, midline, and at the level of the umbilicus. Which of the following findings should the nurse interpret this data as being?

• Evidence of a possible vaginal hematoma B. an indication of a cervical or perineal laceration
• a normal postural discharge of lochia d. abnormally excessive lochia rubra flow

Rationale:

• A client who has a vaginal hematoma is expected to report excessive pain or vaginal pressure.
• Excessive spurting of bright red blood from the vagina indicates a possible cervical or

perineal laceration.

• CORRECT: lochia typically trickles from the vaginal opening but flows more steadily during

uterine contractions. massaging the uterus or ambulation can result in a gush of lochia with the expression of clots and dark blood that has been pooled in the vagina, but it should soon decrease back to a trickle of bright red lochia in the early puerperium.

• Excessive blood loss consists of one pad saturated in 15 min or less or the pooling of blood

under the buttocks, which is not affected by the client's postural changes."

• A nurse is completing postpartum discharge teaching to a client who had no immunity to

varicella and was given varicella vaccine. Which of the following statements by the client indicates understanding of the teaching?

• "i will need to use contraception for 3 months before considering pregnancy."
• "i need a second vaccination at my postpartum visit."
• "i was given the vaccine because my baby is o-positive."
• "i will be tested in 3 months to see if i have developed immunity."

Rationale:

• A client is instructed to not get pregnant for 1 month following administration of varicella

vaccine.

• CORRECT: A second varicella immunization is needed at 4 to 8 weeks following delivery by

clients who had no history of immunity.

• Rho(d) immune globulin is administered to a Rh-Negative mother who has an rh-positive

newborn.

• A client requires testing for immunity at 3 months following administration of rubella vaccine

and rho(d) immune globulin."

• a nurse is assessing a postpartum client for fundal height, location, and consistency. the fundus

is noted to be displaced laterally to the right, and there is uterine atony. the nurse should identify which of the following conditions as the cause of the uterine atony? a. Poor involution B. urinary retention c. hemorrhage d. infection

Rationale:

B "a. Poor involution is the result of uterine atony and does not cause it. B. CORRECT: urinary retention can result in a distention of the bladder. a distended bladder can cause uterine atony and lateral displacement from the midline, usually to the right. c. hemorrhage is the result of uterine atony and does not cause it. d. infection does not cause uterine displacement or atony and would be characterized by foul-smelling vaginal discharge and elevated temperature."

• a nurse is caring for a client who is 1 hr postpartum following a vaginal birth and experiencing

uncontrollable shaking. the nurse should understand that the shaking is due to which of the following factors? (select all that apply.) a. change in body fluids B. metabolic effort of labor c.diaphoresis d. decrease in body temperature E. decrease in prolactin levels

Rationale:

A B "a. CORRECT: a shift in body fluids during the first 2 hr puerperium can cause a postpartum chill. B. CORRECT: the work of labor can cause a postpartum chill during the first 2 hr puerperium. c. diaphoresis is the mechanism by which the excess fluid of pregnancy is removed from the body. it usually occurs within the first 2 to 3 days following delivery. d. an increase in body temperature is associated with a postpartum chill, but it is not the cause of it. E.changes in prolactin levels affect ovulation and menses and are not the cause of a postpartum chill."

• a nurse concludes that the father of an infant is not showing positive signs of parent‑infant

bonding. He appears very anxious and nervous when the infant's mother asks him to bring her the infant. Which of the following actions should the nurse use to promote father‑infant bonding?

• Hand the father the infant, and suggest that he change the diaper. B. ask the father why he is so

anxious and nervous. C. Tell the father that he will grow accustomed to the infant. d. Provide education about infant care when the father is present.

Rationale:

D "a. it is not helpful to push the father into infant care activities without first providing education. B. This is a nontherapeutic statement and presumes the nurse knows what the father is feeling. C. This is a nontherapeutic statement and offers the nurse's opinion. d. CORRECT: nursing interventions to promote paternal bonding include providing education about infant care and encouraging the father to take a hands‑on approach"

• a client in the early postpartum period is very excited and talkative. She is repeatedly telling

the nurse every detail of her labor and birth. Because the client will not stop talking, the nurse is

having difficulty completing the postpartum assessments. Which of the following action should the nurse take? a. Come back later when the client is more cooperative. B. Give the client time to express her feelings. C. Tell the client she needs to be quiet so the assessment can be completed.

• redirect the client's focus so that she will become quiet.

Rationale:

B "a. The nurse should continue her activities while encouraging the client to talk. B.CORRECT: The nurse should recognize that the client in is the taking‑in phase, which begins immediately following birth and lasts a few hours to a couple of days. C. it is not necessary for the client to stop talking while the nurse completes the needed assessments. d. The client is in the taking‑in phase, which includes talking about the birth experience. The client should be encouraged."

• A nurse is caring for a client who is 1 day postpartum. The nurse is assessing for maternal

adaptation and mother‑infant bonding. Which of the following behaviors by the client indicates a need for the nurse to intervene? (Select all that apply.) a. demonstrates apathy when the infant cries B. Touches the infant and maintains close physical proximity C. Views the infant's behavior as uncooperative during diaper changing d. identifies and relates infant's characteristics to those of family members e. interprets the infant's behavior as meaningful and a way of expressing needs

Rationale:

A , C "A CORRECT This behavior demonstrates a lack of interest in the infant and impaired maternal‑infant bonding. B. Touching the infant and maintaining close proximity are signs of effective maternal‑infant bonding. C. CORRECT: a client's view of her infant as being uncooperative during diaper changing is a sign of impaired maternal‑infant bonding. d. endowing the infant with family characteristics indicates effective maternal‑infant bonding. e. recognizing the infant's behavior as meaningful and a way to express needs is an indication of effective maternal‑infant bonding."

• A nurse is caring for a client who is 2 days postpartum. The client states, "My 4‑year old son

was toilet trained and now he is frequently wetting himself." Which of the following statements should the nurse provide to the client? a. "your son was probably not ready for toilet training and should wear training pants." B. "your son is showing an adverse sibling response." C. "your son may need counseling." d. "you should try sending your son to preschool to resolve the behavior."