Which assessment is most important for the nurse to do before the administration of oxytocin?

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.

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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

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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.

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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.

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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:

1.Normal
2.Indicates the presence of infection
3.Indicates the need for increasing oral fluids
4.Indicates the need for increasing ambulation

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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.

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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

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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

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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.

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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

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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.

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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

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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

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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

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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

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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."

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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

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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

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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

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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

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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.

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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

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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
2. Hypothyroidism
3. Hypotension
4. Type 1 diabetes

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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

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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)

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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

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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 immediately postpartum?

1. Lower than during her pregnancy
2. Higher than during her pregnancy
3. Lower than before she became pregnant
4. Higher than before she became pregnant

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28. Which of the following findings would be expected when assessing the postpartum client?

1. Fundus 1 cm above the umbilicus 1 hour postpartum
2. Fundus 1 cm above the umbilicus on postpartum day 3
3. Fundus palpable in the abdomen at 2 weeks postpartum
4. Fundus slightly to the right; 2 cm above umbilicus on postpartum day 2

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29. A client is complaining of painful contractions, or afterpains, on postpartum day 2. Which of the following conditions could increase the severity of afterpains?

1. Bottle-feeding
2. Diabetes
3. Multiple gestation
4. Primiparity

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30. On which of the postpartum days can the client expect lochia serosa?

1. Days 3 and 4 PP
2. Days 3 to 10 PP
3. Days 10-14 PP
4. Days 14 to 42 PP

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31. Which of the following behaviors characterizes the PP mother in the taking in phase?

1. Passive and dependant
2. Striving for independence and autonomy
3. Curious and interested in care of the baby
4. Exhibiting maximum readiness for new learning

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32. Which of the following complications may be indicated by continuous seepage of blood from the vagina of a PP client, when palpation of the uterus reveals a firm uterus 1 cm below the umbilicus?

1. Retained placental fragments
2. Urinary tract infection
3. Cervical laceration
4. Uterine atony

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33. What type of milk is present in the breasts 7 to 10 days PP?

1. Colostrum
2. Hind milk
3. Mature milk
4. Transitional milk

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34. Which of the following complications is most likely responsible for a delayed postpartum hemorrhage?

1. Cervical laceration
2. Clotting deficiency
3. Perineal laceration
4. Uterine subinvolution

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35. Before giving a PP client the rubella vaccine, which of the following facts should the nurse include in client teaching?

1. The vaccine is safe in clients with egg allergies
2. Breast-feeding isn't compatible with the vaccine
3. Transient arthralgia and rash are common adverse effects
4. The client should avoid getting pregnant for 3 months after the vaccine because the vaccine has teratogenic effects

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36. Which of the following changes best described the insulin needs of a client with type 1 diabetes who has just delivered an infant vaginally without complications?

1. Increase
2. Decrease
3. Remain the same as before pregnancy
4. Remain the same as during pregnancy

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37. Which of the following responses is most appropriate for a mother with diabetes who wants to breastfeed her infant but is concerned about the effects of breastfeeding on her health?

1. Mothers with diabetes who breast-feed have a hard time controlling their insulin needs
2. Mothers with diabetes shouldn't breastfeed because of potential complications
3. Mothers with diabetes shouldn't breastfeed; insulin requirements are doubled.
4. Mothers with diabetes may breastfeed; insulin requirements may decrease from breastfeeding.

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38. On the first PP night, a client requests that her baby be sent back to the nursery so she can get some sleep. The client is most likely in which of the following phases?

1. Depression phase
2. Letting-go phase
3. Taking-hold phase
4. Taking-in phase

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39. Which of the following physiological responses is considered normal in the early postpartum period?

1. Urinary urgency and dysuria
2. Rapid diuresis
3. Decrease in blood pressure
4. Increase motility of the GI system

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40. During the 3rd PP day, which of the following observations about the client would the nurse be most likely to make?

1. The client appears interested in learning about neonatal care
2. The client talks a lot about her birth experience
3. The client sleeps whenever the neonate isn't present
4. The client requests help in choosing a name for the neonate.

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41. Which of the following circumstances is most likely to cause uterine atony and lead to PP hemorrhage?

1. Hypertension
2. Cervical and vaginal tears
3. Urine retention
4. Endometritis

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42. Which type of lochia should the nurse expect to find in a client 2 days PP?

1. Foul-smelling
2. Lochia serosa
3. Lochia alba
4. Lochia rubra

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43. After expulsion of the placenta in a client who has six living children, an infusion of lactated ringer's solution with 10 units of pitocin is ordered. The nurse understands that this is indicated for this client because:

1. She had a precipitate birth
2. This was an extramural birth
3. Retained placental fragments must be expelled
4. Multigravida's are at increased risk for uterine atony.

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44. As part of the postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding woman who is one day postpartum. An expected finding would be:

1. Soft, non-tender; colostrum is present
2. Leakage of milk at let down
3. Swollen, warm, and tender upon palpation
4. A few blisters and a bruise on each areola

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45. Following the birth of her baby, a woman expresses concern about the weight she gained during pregnancy & how quickly she can lose it now that the baby is born. The nurse, in describing the expected pattern of weight loss, shld begin by telling her that:

1.Return to prepregnant weight is usually achieved by the end of the postpartum period
2.Fluid loss from diuresis, diaphoresis, and bleeding accounts for about a 3 pound weight loss
3.The expected weight loss immediately after birth averages about 11 to 13 pounds
4.Lactation will inhibit weight loss since caloric intake must increase to support milk production

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46. Which of the following findings would be a source of concern if noted during the assessment of a woman who is 12 hours postpartum?

1. Postural hypotension
2. Temperature of 100.4°F
3. Bradycardia — pulse rate of 55 BPM
4. Pain in left calf with dorsiflexion of left foot

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47. The nurse examines a woman one hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action would be to:

1. Place her on a bedpan to empty her bladder
2. Massage her fundus
3. Call the physician
4. Administer Methergine 0.2 mg IM which has been ordered prn

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48. When performing a postpartum check, the nurse should:

1.Assist the woman into a lateral position with upper leg flexed forward to facilitate the examination of her perineum
2.Assist the woman into a supine position with her arms above her head and her legs extended for the examination of her abdomen
3.Instruct the woman to avoid urinating just before the examination since a full bladder will facilitate fundal palpation
4.Wash hands and put on sterile gloves before beginning the check

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49. Perineal care is an important infection control measure. When evaluating a postpartum woman's perineal care technique, the nurse would recognize the need for further instruction if the woman:

1.Uses soap and warm water to wash the vulva and perineum
2.Washes from symphysis pubis back to episiotomy
3.Changes her perineal pad every 2 - 3 hours
4.Uses the peribottle to rinse upward into her vagina

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50. Which measure would be least effective in preventing postpartum hemorrhage?

1. Administer Methergine 0.2 mg every 6 hours for 4 doses as ordered
2.Encourage the woman to void every 2 hours
3.Massage the fundus every hour for the first 24 hours following birth
4.Teach the woman the importance of rest and nutrition to enhance healing

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51. When making a visit to the home of a postpartum woman one week after birth, the nurse should recognize that the woman would characteristically:

1.Express a strong need to review events and her behavior during the process of labor and birth
2.Exhibit a reduced attention span, limiting readiness to learn
3.Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn
4.Have reestablished her role as a spouse/partner

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52. Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just wants to sleep. The nurse should:

1.Tell the woman she can rest after she feeds her baby
2.Recognize this as a behavior of the taking-hold stage
3.Record the behavior as ineffective maternal-newborn attachment
4.Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time

53. Parents can facilitate the adjustment of their other children to a new baby by:

1.Having the children choose or make a gift to give to the new baby upon its arrival home
2.Emphasizing activities that keep the new baby and other children together
3.Having the mother carry the new baby into the home so she can show the other children the new baby
4.Reducing stress on other children by limiting their involvement in the care of the new baby

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54. A primiparous woman is in the taking-in stage of psychosocial recovery and adjustment following birth. The nurse, recognizing the needs of women during this stage, should:

1.Foster an active role in the baby's care
2.Provide time for the mother to reflect on the events of and her behavior during childbirth
3.Recognize the woman's limited attention span by giving her written materials to read when she gets home rather than doing a teaching session now
4.Promote maternal independence by encouraging her to meet her own hygiene and comfort needs

What are the nursing responsibilities in administering oxytocin?

What should you monitor after administering oxytocin?

What should be observed during oxytocin infusion?

What nursing interventions should you perform prior to starting induction of labor?