OB Postpartum NCLEX Questions

OB Postpartum NCLEX Questions ScienceMedicineNursing ashley_coots7 Save Postpartum NCLEX Style Questions 20 terms christa_hintonPreview Newborn Nursing Care and Assess...42 terms emlicataPreview Postpartum NCLEX 40 terms lmr2333Preview Matern 68 terms cry 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:

• Every 30 minutes during the first hour and then every hour for the next two hours.
• Every 15 minutes during the first hour and then every 30 minutes for the next two hours.
• Every hour for the first 2 hours and then every 4 hours
• Every 5 minutes for the first 30 minutes and then every hour for the next 4 hours.
• Every 15 minutes during the first hour and then every 30 minutes for the next two hours.

Rationale: Every 15 minutes during the first hour and then every 30 minutes for the next two hours.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?

• Retake the temperature in 15 minutes
• Notify the physician
• Document the findings
• Increase hydration by encouraging oral fluids
• Increase hydration by encouraging oral fluids

Rationale: The mother's temperature may be taken every 4 hours while she is awake. Temperatures up to 100.4 (38 C) in the first 24 hours after birth are often related to the dehydrating effects of labor. The most appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. Although the nurse would document the findings, the most appropriate action would be to increase the hydration.

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?

• Obtain hemoglobin and hematocrit levels
• Instruct the mother to request help when getting out of bed
• Elevate the mother's legs
• Inform the nursery room nurse to avoid bringing the newborn infant to the mother until the feelings of lightheadedness and dizziness have

subsided

• Instruct the mother to request help when getting out of bed

Rationale: Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that should caution the nurse to be aware of the client's safety. The nurse should advise the mother to get help the first few times the mother gets out of bed. Obtaining an H/H requires a physicians order.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?

• Ask the client to turn on her side
• Ask the client to lie flat on her back with the knees and legs flat and straight
• Ask the mother to urinate and empty her bladder
• Massage the fundus gently before determining the level of the fundus.
• Ask the mother to urinate and empty her bladder

Rationale: Before starting the fundal assessment, the nurse should ask the mother to empty her bladder so that an accurate assessment can be done. When the nurse is performing fundal assessment, the nurse asks the woman to lie flat on her back with the knees flexed. Massaging the fundus is not appropriate unless the fundus is boggy and soft, and then it should be massaged gently until firm.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:

• Normal
• Indicates the presence of infection
• Indicates the need for increasing oral fluids
• Indicates the need for increasing ambulation
• Indicates the presence of infection

Rationale: Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor. Foul smelling or purulent lochia usually indicates infection, and these findings are not normal. Encouraging the woman to drink fluids or increase ambulation is not an accurate nursing intervention 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?

• Document the findings
• Notify the physician
• Reassess the client in 2 hours
• Encourage increased intake of fluids
• Notify the physician

Rationale: Normally, one may find a few small clots in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the most appropriate action is to notify the physician.

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:

• One peripad per day
• Two peripads per day
• Three peripads per day
• Eight peripads per day
• Eight peripads per day

Rationale: The normal amount of lochia may vary with the individual but should never exceed 4 to 8 peripads per day. The average number of peripads is 6 per day.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:

• One the day of the delivery
• 3 days PP
• 7 days PP
• within 2 weeks PP
• 3 days PP

Rationale: After birth, the nurse should auscultate the woman's abdomen in all four quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days PP. Surgery, anesthesia, and the use of narcotics and pain control agents also contribute to the longer period of altered bowel function Select all of the physiological maternal changes that occur during the PP period. (Select all that apply)

• Cervical involution occurs
• Vaginal distention decreases slowly
• Fundus begins to descend into the pelvis after 24 hours
• Cardiac output decreases with resultant tachycardia in the first 24 hours
• Digestive processes slow immediately
• Cervical involution occurs
• Fundus begins to descend into the pelvis after 24 hours

Rationale: After 1 week the muscle begins to regenerate and the cervix feels firm and the external os is the width of a pencil. Although the vaginal mucosa heals and vaginal distention decreases, it takes the entire PP period for complete involution to occur and muscle tone is never restored to the pregravid state. The fundus begins to descent into the pelvic cavity after 24 hours, a process known as involution. Despite blood loss that occurs during delivery of the baby, a transient increase in cardiac output occurs. The increase in cardiac output, which persists about 48 hours after childbirth, is probably caused by an increase in stroke volume because Bradycardia is often noted during the PP period. Soon after childbirth, digestion begins to begin to be active and the new mother is usually hungry because of the energy expended during labor.

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?

• Complaints of a tearing sensation
• Complaints of intense pain
• Changes in vital signs
• Signs of heavy bruising
• Changes in vital signs

Rationale: Because the woman has had epidural anesthesia and is anesthetized, she cannot feel pain, pressure, or a tearing sensation. Changes in vitals indicate hypovolemia in the anesthetized PP woman with vulvar hematoma. Heavy bruising may be visualized, but vital sign changes indicate hematoma caused by blood collection in the perineal tissues.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?

• Assess vital signs every 4 hours
• Inform health care provider of assessment findings
• Measure fundal height every 4 hours
• Prepare an ice pack for application to the area.
• Prepare an ice pack for application to the area.

Rationale: Application of ice will reduce swelling caused by hematoma formation in the vulvar area. The other options are not interventions that are specific to the plan of care for a client with a small vulvar hematoma.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:

• Monitor fundal height
• Apply perineal pressure
• Prepare the client for surgery.
• Reassure the client
• Prepare the client for surgery.

Rationale: The use of an epidural, prolonged second stage labor and forceps delivery are predisposing factors for hematoma formation, and a collection of up to 500 ml of blood can occur in the vaginal area. Although the other options may be implemented, the immediate action would be to prepare the client for surgery to stop the bleeding.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?

• A temperature of 100.4*F
• An increase in the pulse from 88 to 102 BPM
• An increase in the respiratory rate from 18 to 22 breaths per minute
• A blood pressure change from 130/88 to 124/80 mm Hg
• An increase in the pulse from 88 to 102 BPM

Rationale: During the 4th stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. A rising pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. The blood pressure will fall as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage. A slight rise in temperature is normal. The respiratory rate is increased slightly.