OB Postpartum NCLEX Questions

NCLEX - Postpartum Care Leave the first rating Students also studied Terms in this set (72) Science MedicineObstetrics Save OB Postpartum NCLEX Questions 52 terms ashley_coots7 Preview Postpartum NCLEX 40 terms lmr2333Preview Labor and Delivery Nclex style ques...46 terms athingofaithPreview NCLEX 110 term kan A 25 year-old woman gave birth to her second child 6 hours ago. She informs the nurse that she is bleeding more than with her previous birth experience. The initial

nursing action is to:

• Explain that this is normal for second-time moms.
• Assess the location and firmness of the fundus.
• Change her pad and return in 1 hour and reassess.
• Give her 10 units of oxytocin as per standing order.

ANS: b

• The nurse should not inform the patient that this is normal until she has assessed

for the degree and potential cause of bleeding.

• It is important to first assess for uterine atony or displaced uterus from full

bladder.

• If the uterus is firm and midline, then the nurse should change the pad and

return within 30 minutes to assess the amount of lochia.

• The nurse would give oxytocin if the uterus is boggy and does not respond to

uterine massage.Which of these medications is commonly used to control postpartum bleeding related to uterine atony?

• Magnesium sulfate
• Phytonadione
• Oxytocin
• Warfarin

ANS: c

• Magnesium sulfate is commonly used for PIH and preterm labor. It is a smooth

muscle relaxant and can cause the uterus to relax.

• Phytonadione (vitamin K) is important for clotting but will not cause the uterus

to contract.

• Oxytocin is commonly used to control postpartum bleeding related to uterine

atony.

• Warfarin is an anticoagulant and will increase the risk of hemorrhage.

During a postpartum assessment, the nurse notes that the uterus is midline and boggy. The immediate nursing

action is:

• To notify the patients midwife or physician
• Massage the fundus until firm and reevaluate within 30

minutes

• Give Syntocinon as per orders
• Assist the patient to the bathroom and ask her to void

ANS: b

• If the uterus does not respond to massage, then the nurse would give

Syntocinon and notify the primary health provider.

• The first nursing action for a boggy uterus is to massage the fundus.
• If the uterus does not respond to massage, then the nurse would give

Syntocinon and notify the primary health provider.

• You would assist the woman to the bathroom if the uterus is boggy and

displaced to the side.

On day four following the birth of an average size baby,

the nurse would expect the fundus to be at:

• 1 cm below umbilicus
• 2 cm below umbilicus
• 3 cm below umbilicus
• 4 cm below umbilicus

ANS: d

• Expected location for day 1
• Expected location for day 2
• Expected location for day 3
• Correct. The uterus on the average descends 1 centimeter per day.

A nurse is preparing to administer RhoGam to a client who delivered a fetal demise. Which of the following must the nurse check before giving the injection?

• Verify that the direct Coombs test results are positive.
• Check that the fetus was at least 28 weeks gestation.
• Make sure that the client is at least 3 days postdelivery.
• Confirm that the client is Rh negative.

ANS: d

• The direct Coombs test is irrelevant, and because the baby has died, the

Coombs will likely not be performed.

• RhoGam should be given no matter how old the fetus was.
• RhoGam must be administered before 72 hours postpartum.
• RhoGam is contraindicated for clients who are Rh+ (positive). The nurse must

confirm that any client receiving RhoGam is Rh negative.A nurse is performing a postpartum assessment 30 minutes after a vaginal delivery. Which of the following actions indicates that the nurse is performing the assessment correctly?

• The nurse measures the fundal height in relation to the

symphysis pubis.

• The nurse monitors the clients central venous pressure.
• The nurse assesses the clients perineum for edema and

ecchymoses.

• The nurse performs a sterile vaginal speculum exam.

ANS: c

• The fundal height should be measured in relation to the umbilicus.
• The central venous pressure is not monitored during postpartum assessments.
• The nurse should assess the perineum for signs of edema and ecchymoses.
• If a speculum exam were needed, a physician or midwife would perform the

procedure. Speculum exams are rarely needed postpartum.A woman is 2 days postpartum from a normal vaginal delivery over an intact perineum of a 3000-gram baby.Where would the nurse expect to palpate the clients fundus?

• At the umbilicus
• 2 cm below the umbilicus
• 2 cm above the symphysis
• At the symphysis

ANS: b

• Expected location for 6 to 12 hours postpartum.
• The firm fundus should be 2 cm below the umbilicus.
• This is an abnormal finding and may be related to subinvolution of the uterus.
• Expected location for 6 days postpartum.

Which of the following clients is most likely to complain of afterbirth pains during her postpartum period?

• G1 P0, diagnosed with preeclampsia
• G2 P0, group B streptococci in the vagina
• G3 P2, gave birth to a 4100-gram baby
• G4 P1, diagnosed with preterm labor

ANS: c

• This client is a primipara. The nurse would not expect her to complain

excessively of afterbirth pains.

• This client is a primipara. The nurse would not expect her to complain

excessively of afterbirth pains.

• This client is a multipara and she delivered a macrosomic baby. She is likely to

complain of severe afterbirth pains.

• Although this client is a gravida 4, she is a para 1. The nurse would not expect

her to complain excessively of afterbirth pains.

The nurse is providing discharge counseling to a woman who is breastfeeding her baby. The nurse advises the woman that if she experiences unilateral breast inflammation, she should do which of the following?

• Apply warm soaks to the reddened area.
• Consume an herbal galactagogue.
• Bottle feed the baby during the next day.
• Take expressed breast milk to the laboratory for

analysis.

ANS: a

• The client may be developing mastitis. She should apply warm soaks to the

area.

• There is no need for a galactagogue.
• It is essential that the client continue to breastfeed. If she were to stop feeding,

she could develop a breast abscess.

• Unless ordered by the physician, the milk need not be cultured.

The nurse is working with a 36-year-old, married client, G6 P6, who smokes. The woman states, I dont expect to have any more kids, but I hate the thought of being sterile. Which of the following contraceptive methods would be best for the nurse to recommend to this client?

• Intrauterine device
• Contraceptive patch
• Bilateral tubal ligation
• Birth control pills

ANS: a

• An intrauterine device (IUD) is an excellent contraceptive method for women

who have had at least one delivery, are in a monogamous relationship, and wish to have long-term contraception.

• The contraceptive patch is not recommended for women over 35 or for women

who smoke.

• A bilateral tubal ligation is a sterilization procedure.
• Birth control pills are not recommended for women over 35 or for women who

smoke.The perinatal nurse demonstrates for the student nurse the correct technique of postpartum uterine palpation.Support for the lower uterine segment is critical, as

without it, there is an increased risk of:

• Uterine edema
• Uterine inversion
• Incorrect measurement
• Intensifying the patients level of pain

ANS: b

• Placing the hand over the base of the uterus does not cause uterine edema.
• The uterine fundus is palpated by placing one hand on the base of the uterus

immediately above the symphysis pubis and the other hand at the level of the umbilicus. The nurse presses inward and downward with the hand positioned on the umbilicus until the fundus is located. It should feel like a firm, globular mass located at or slightly above the umbilicus during the first hour after birth. The uterus should never be palpated without supporting the lower uterine segment.Failure to do so may result in uterine inversion and hemorrhage.

• Measurement is the same with or without the hand supporting the lower uterine

segment.

• Not supporting the lower uterine segment has no effect on the level of pain felt

by the patient.Maddy, a G3 P1 woman, gave birth 12 hours ago to a 9 lb.13 oz. daughter. She experiences severe cramps with breastfeeding. The perinatal nurse best describes this

condition as:

• Afterpains
• Uterine hypertonia
• Bladder hypertonia
• Rectus abdominis diastasis

ANS: A - Afterpains (afterbirth pains) are intermittent uterine contractions that occur during the process of involution. Afterpains are more pronounced in patients with decreased uterine tone due to overdistension, which is associated with multiparity and macrosomia. Patients often describe the sensation as a discomfort similar to menstrual cramps.

A 35-year-old G1 P0 postpartum woman is Rh0(D)- negative and needs Rh0(D) immune globulin to be administered. The most appropriate dose that the

perinatal nurse would expect to be ordered would be:

• 120 ug
• 250 ug
• 300 ug
• 350 ug

ANS: c - Nonsensitized women who are Rh0(D)-negative and have given birth to

an Rh(D)-positive infant should receive 300 ug of Rh0(D) immune globulin (RhoGAM) within 72 hours after giving birth. RhoGAM should be given whether or not the mother received RhoGAM during the antepartum period. In some situations, depending on the extent of hemorrhage and exchange of maternalfetal blood, a larger dose of RhoGAM may be indicated.Heather, a postpartum woman who experienced a spontaneous vaginal birth 12 hours ago, describes a headache that is worsening. Heather was given two regular strength acetaminophen (Tylenol) tablets approximately 30 minutes ago but has had no relief from the pain. Several friends and family members are presently visiting Heather. The nurse notes that Heathers pain relief during labor consisted of a single dose of an IM narcotic. The most appropriate nursing action at this

time is to:

• Notify Heathers health-care provider about Heathers

headache.

• Dim the lights in Heathers room so that she is able to

get some rest.

• Ask Heathers visitors to leave now to decrease

Heathers environmental stimuli.

• Ask Heather where she is experiencing this headache

and to identify the pain score that best describes the intensity of the pain.

ANS: d - The nurse should perform routine, comprehensive pain assessments to

include onset, location, intensity, quality, characteristics, and aggravating and alleviating factors of the discomfort in order to provide interventions in a timely manner and enhance effectiveness of medications. The nurse should also ask the patient to rate her pain on a standard 0 to 10 pain scale before and after interventions and to identify her own acceptable comfort level on the scale.The perinatal nurse teaches the postpartum woman about the normal process of diuresis that she can expect to occur approximately 6 to 8 hours after birth. A decrease in which of the following hormones is primarily responsible for the diuresis?

• Prolactin
• Progesterone
• Oxytocin
• Estrogen

ANS: d - Maternal diuresis occurs almost immediately after birth and urinary

output reaches up to 3000 mL each day by the second to fifth postpartum days.After childbirth, a decrease in the level of estrogen naturally occurs and contributes to the diuresis.