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:
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?
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?
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?
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:
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?
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:
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:
9. Select all of the physiological maternal changes that occur during the PP period.
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?
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?
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:
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?
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?
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?
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?
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:
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:
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?
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?
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.
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:
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?
24. Which of the following factors might result in a decreased supply of breast milk in a PP mother?
25. Which of the following interventions would be helpful to a breastfeeding mother who is experiencing engorged breasts?
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?
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?
28. Which of the following findings would be expected when assessing the postpartum client?
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?
30. On which of the postpartum days can the client expect lochia serosa?
31. Which of the following behaviors characterizes the PP mother in the taking in phase?
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?
33. What type of milk is present in the breasts 7 to 10 days PP?
34. Which of the following complications is most likely responsible for a delayed postpartum hemorrhage?
35. Before giving a PP client the rubella vaccine, which of the following facts should the nurse include in client teaching?
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?
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?
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?
39. Which of the following physiological responses is considered normal in the early postpartum period?
40. During the 3rd PP day, which of the following observations about the client would the nurse be most likely to make?
41. Which of the following circumstances is most likely to cause uterine atony and lead to PP hemorrhage?
42. Which type of lochia should the nurse expect to find in a client 2 days PP?
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:
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:
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:
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?
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:
48. When performing a postpartum check, the nurse should:
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:
50. Which measure would be least effective in preventing postpartum hemorrhage?
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:
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:
53. Parents can facilitate the adjustment of their other children to a new baby by:
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:
What are the nursing responsibilities in administering oxytocin?
The nurse must have sound knowledge about the physiology of uterine contractions and the phamacodynamics and pharmacokinetics of oxytocin. In addition, the nurse must be proficient at maternal-fetal assessment, including palpation of contractions and interpretation of electronic fetal heart rate monitor tracings.
What should you monitor after administering oxytocin?
It is essential to monitor patient fluids (both intake and outtake) while administering oxytocin and the frequency of uterine contractions, patient blood pressure, and heart rate of the unborn fetus.
What should be observed during oxytocin infusion?
Electronically monitor the uterine activity and the fetal heart rate throughout the infusion of Pitocin. Attention should be given to tonus, amplitude and frequency of contractions, and to the fetal heart rate in relation to uterine contractions.
What nursing interventions should you perform prior to starting induction of labor?
Monitor fetal heart tones immediately before, during, and after the procedure. Observe and record color, amount, and odor of amniotic fluid; time of procedure; cervical status; and materbal temperature. Take and record the client's temperature every 2 hours to assess for infection. Monitor for the onset of labor.