Maternity - Postpartum

A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply.
1. Breast-feeding needs to be stopped for 3 months.
2. Pregnancy needs to be avoided for 1 to 3 months.
3. The vaccine is administered by the subcutaneous route.
4. Exposure to immunosuppressed individuals needs to be avoided.
5. A hypersensitivity reaction can occur if the client has an allergy to eggs.
6. The area of the injection needs to be covered with a sterile gauze for 1 week.

The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client?
1. "You will need to bottle-feed your newborn."
2. "You will need to feed your newborn by nasogastric tube feeding."
3. "You will be able to breast-feed for 6 months and then will need to switch to bottle-feeding."
4. "You will be able to breast-feed for 9 months and then will need to switch to bottle-feeding."

A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would further assist the family in their initial period of grief?
1. "What can I do for you?"
2. "Now you have an angel in heaven."
3. "Don't worry, there is nothing you could have done to prevent this from happening."
4. "We will see to it that you have an early discharge so that you don't have to be reminded of this experience."

The nurse in a maternity unit is providing emotional support to a client and her husband who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process?
1. "We want to attend a support group."
2. "We never want to try to have a baby again."
3. "We are going to try to adopt a child immediately."
4. "We are okay, and we are going to try to have another baby immediately."

The nurse evaluates the ability of a hepatitis B–positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn?
1. The mother requests that the window be closed before feeding.
2. The mother holds the newborn properly during feeding and burping.
3. The mother tests the temperature of the formula before initiating feeding.
4. The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding.

The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction?
1. "I will begin abdominal exercises immediately."
2. "I will notify the health care provider if I develop a fever."
3. "I will turn on my side and push up with my arms to get out of bed."
4. "I will lift nothing heavier than my newborn baby for at least 2 weeks."

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn infant briefly with her fingertips. What should the nurse do to help the woman process the delivery?
1. Encourage the mother to breast-feed soon after birth.
2. Support the mother in her reaction to the newborn infant.
3. Tell the mother that it is important to hold the newborn infant.
4. Document a complete account of the mother's reaction on the birth record.

The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with a placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa?
1. Infection
2. Hemorrhage
3. Chronic hypertension
4. Disseminated intravascular coagulation

The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2° F. What is the priority nursing action?
1. Document the findings.
2. Retake the temperature in 15 minutes.
3. Notify the health care provider (HCP).
4. Increase hydration by encouraging oral fluids.

The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action would be most appropriate?
1. Raise the head of the client's bed.
2. Obtain hemoglobin and hematocrit levels.
3. Instruct the client to request help when getting out of bed.
4. Inform the nursery room nurse to avoid bringing the newborn to the client until the mother's symptoms have subsided.

The postpartum nurse is providing instructions to a client after delivery of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function?
1. 3 days postpartum
2. 7 days postpartum
3. On the day of delivery
4. Within 2 weeks postpartum

The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client had a midline episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client?
1. Client pain level
2. Inadequate urinary output
3. Client perception of body changes
4. Potential for imbalanced body fluid volume

The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all that apply.
1. "I should wear a bra that provides support."
2. "Drinking alcohol can affect my milk supply."
3. "The use of caffeine can decrease my milk supply."
4. "I will start my estrogen birth control pills again as soon as I get home."
5. "I know if my breasts get engorged I will limit my breast-feeding and supplement the baby."
6. "I plan on having bottled water available in the refrigerator so I can get additional fluids easily."

The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include?
1. The diet should include additional fluids.
2. Prenatal vitamins should be discontinued.
3. Soap should be used to cleanse the breasts.
4. Birth control measures are unnecessary while breast-feeding.

A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention would be most appropriate?
1. Elevate the client's legs.
2. Massage the fundus until it is firm.
3. Ask the client to turn on her left side.
4. Push on the uterus to assist in expressing clots.

The nurse is caring for four 1-day postpartum clients. Which client would require further nursing action?
1. The client with mild afterpains
2. The client with a pulse rate of 60 beats/minute
3. The client with colostrum discharge from both breasts
4. The client with lochia that is red and has a foul-smelling odor

When performing a postpartum assessment on a client, a nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate?
1. Document the findings.
2. Reassess the client in 2 hours.
3. Notify the health care provider.
4. Encourage increased oral intake of fluids.

The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 1 hour. How should the nurse document this finding?
1. Scant
2. Light
3. Heavy
4. Excessive

The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss?
1. A temperature of 100.4° F
2. An increase in the pulse rate from 88 to 102 beats/minute
3. A blood pressure change from 130/88 to 124/80 mm Hg
4. An increase in the respiratory rate from 18 to 22 breaths/minute

The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply.
1. Wear a supportive bra.
2. Rest during the acute phase.
3. Maintain a fluid intake of at least 3000 mL.
4. Continue to breast-feed if the breasts are not too sore.
5. Take the prescribed antibiotics until the soreness subsides.
6. Avoid decompression of the breasts by breast-feeding or breast pump.

The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction?
1. "I should breast-feed every 2 to 3 hours."
2. "I should change the breast pads frequently."
3. "I should wash my hands well before breast-feeding."
4. "I should wash my nipples daily with soap and water."

The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign would the nurse note if superficial venous thrombosis were present?
1. Paleness of the calf area
2. Coolness of the calf area
3. Enlarged, hardened veins
4. Palpable dorsalis pedis pulses

A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action?
1. Initiate an intravenous line.
2. Assess the client's blood pressure.
3. Prepare to administer morphine sulfate.
4. Administer oxygen, 8 to 10 L/minute, by face mask.

The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action?
1. Record the findings.
2. Massage the fundus.
3. Notify the health care provider (HCP).
4. Place the client in Trendelenburg's position.

The nurse is preparing to care for four assigned clients. Which client is at highest risk for hemorrhage?
1. A primiparous client who delivered 4 hours ago
2. A multiparous client who delivered 6 hours ago
3. A primiparous client who delivered 6 hours ago and had epidural anesthesia
4. A multiparous client who delivered a large baby after oxytocin (Pitocin) induction

A postpartum client is diagnosed with cystitis. The nurse should plan for which priority nursing action in the care of the client?
1. Providing sitz baths
2. Encouraging fluid intake
3. Placing ice on the perineum
4. Monitoring hemoglobin and hematocrit levels

The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma?
1. Changes in vital signs
2. Signs of heavy bruising
3. Complaints of intense pain
4. Complaints of a tearing sensation

The nurse is developing a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery?
1. Assess vital signs every 4 hours.
2. Measure fundal height every 4 hours.
3. Prepare an ice pack for application to the area.
4. Inform the health care provider of assessment findings.

On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action?
1. Elevate the client's legs.
2. Document the findings.
3. Massage the fundus until it is firm.
4. Push on the uterus to assist in expressing clots.

On the second postpartum day, a client complains of burning on urination, urgency, and frequency of urination. A urinalysis indicates the presence of a urinary tract infection. The nurse instructs the client regarding measures to take for the treatment of the infection. Which client statement indicates to the nurse the need for further instruction?
1. "I need to urinate frequently throughout the day."
2. "The prescribed medication must be taken until it is finished."
3. "My fluid intake should be increased to at least 3000 mL daily."
4. "Foods and fluids that will increase urine alkalinity should be consumed."

The nurse is assessing a client for signs of postpartum depression. Which observation, if noted in the new mother, would indicate the need for further assessment related to this form of depression?
1. The mother is caring for the infant in a loving manner.
2. The mother demonstrates an interest in the surroundings.
3. The mother constantly complains of tiredness and fatigue.
4. The mother looks forward to visits from the father of the newborn.

A postpartum client is attempting to breast-feed for the first time. The nurse notes that the client has inverted nipples. What nursing action should the nurse take to assist the client in breast-feeding the newborn infant?
1. Massage the breasts, applying gentle pressure on the areolas with the thumb and forefinger.
2. Have the mother grasp her areola between the thumb and forefinger and tug firmly to get the nipple to protrude.
3. Encourage taking a cool shower, allowing the water to run over the breasts, because this will encourage the nipples to protrude.
4. Provide breast shells and assist the mother with using a breast pump before each feeding to make the nipples easier for the newborn infant to grasp.

A new mother is seen in a health care clinic 2 weeks after giving birth to a healthy newborn infant. The mother is complaining that she feels as though she has the flu and complains of fatigue and aching muscles. On further assessment the nurse notes a localized area of redness on the left breast, and the mother is diagnosed with mastitis. The mother asks the nurse about the condition. The nurse should make which response?
1. "Mastitis usually involves both breasts."
2. "Mastitis can occur at any time during breast-feeding."
3. "Mastitis usually is caused by wearing a supportive bra."
4. "Mastitis is most common for women who have breast-fed in the past."

The nurse is developing a plan of care for a client recovering from a cesarean delivery. Which action should the nurse encourage the client to do to prevent thrombophlebitis?
1. Elevate her legs.
2. Remain on bed rest.
3. Ambulate frequently.
4. Apply warm, moist packs to the legs.

The nurse performs an assessment on a client who is 4 hours postpartum. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. What immediate action should the nurse take?
1. Provide oral fluids and begin fundal massage.
2. Begin hourly pad counts and reassure the client.
3. Elevate the head of the bed and assess vital signs.
4. Assess for hypovolemia and notify the health care provider (HCP).

The nurse is monitoring a postpartum client in the fourth stage of labor. Which finding, if noted by the nurse, would indicate a complication related to a laceration of the birth canal?
1. Presence of dark red lochia
2. Palpation of the uterus as a firm contracted ball
3. The saturation of more than one peripad per hour
4. Palpation of the fundus at the level of the umbilicus

The nurse is providing instructions to a client who has been diagnosed with mastitis. Which statement, if made by the client, indicates a need for further instructions?
1. "I need to wear a supportive bra to relieve the discomfort."
2. "I need to stop breast-feeding until this condition resolves."
3. "I can use analgesics to assist in alleviating some of the discomfort."
4. "I need to take antibiotics, and I should begin to feel better in 24 to 48 hours."

A postpartum client with deep vein thrombosis is being treated with anticoagulant therapy. The nurse understands that the client's response to treatment will be evaluated by regularly assessing the client for which symptoms?
1. Dysuria, ecchymosis, and vertigo
2. Epistaxis, hematuria, and dysuria
3. Hematuria, ecchymosis, and vertigo
4. Hematuria, ecchymosis, and epistaxis

After surgical evacuation and repair of a paravaginal hematoma, a client is discharged 3 days postpartum. The nurse determines that the client needs further discharge instructions when the client makes which statement?
1. "I will probably need my mother to help me with housekeeping."
2. "Because I am so sore, I will nurse the baby while lying on my side."
3. "My husband and I will not have intercourse until the stitches are healed."
4. "The only medications I will take are prenatal vitamins and stool softeners."

The nurse is developing a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse anticipates that which intervention will be prescribed?
1. Administration of anticoagulants
2. Elevation of the affected extremity
3. Ambulation eight to ten times daily
4. Application of ice packs to the affected area

A new mother received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum her systolic blood pressure has dropped 20 points, her diastolic blood pressure has dropped 10 points, and her pulse is 120 beats/min. The client is anxious and restless. On further assessment, a vulvar hematoma is verified. After notifying the health care provider, what is the nurse's next action?
1. Reassure the client.
2. Monitor fundal height.
3. Apply perineal pressure.
4. Prepare the client for surgery.

The home care nurse visits a client who has delivered a healthy newborn infant via vaginal delivery. An episiotomy was performed, and the woman has developed a wound infection at the episiotomy site. The nurse provides instructions to the client regarding care related to the infection. Which statement, if made by the mother, indicates a need for further instructions?
1. "I need to take the antibiotics as prescribed."
2. "I need to take warm sitz baths to promote healing."
3. "I need to apply warm compresses to provide comfort."
4. "I need to isolate the infant for 48 hours after beginning the antibiotics."

A client has just had surgery to deliver a nonviable fetus resulting from abruptio placentae. As a result of the abruptio placentae, the client develops disseminated intravascular coagulation (DIC) and is told about the complication. The client begins to cry and screams, "God, just let me die now!" Which client problem should be the priority for the client at this time?
1. Lack of power about the situation
2. Grieving because of the loss of the baby
3. Lack of knowledge regarding what occurred
4. Concern about the loss of the baby and personal health

The rubella vaccine has been prescribed for a new mother. Which statement should the postpartum nurse make when providing information about the vaccine to the client?
1. "You should avoid sexual intercourse for 2 weeks after administration of the vaccine."
2. "You should not become pregnant for 2 to 3 months after administration of the vaccine."
3. "You should avoid heat and extreme temperature changes for 1 week after administration of the vaccine."
4. "You must sign an informed consent because anaphylactic reactions can occur with the administration of this vaccine."

The nursing student is assigned to care for a client in the postpartum unit. The coassigned nurse asks the student to identify the most objective method to assess the amount of lochial flow in the client. Which statement, if made by the student, indicates an understanding of this method?
1. "I can estimate the amount of blood loss by gauging the amount of staining on a perineal pad."
2. "I should ask the client to keep a record and document every time the perineal pad is changed."
3. "I should weigh the perineal pad before and after use and note the amount of time between each pad change."
4. "I can look at the perineal pad and gauge the amount of staining and relate it to the amount of time between pad changes."

The nurse in the postpartum unit is observing the mother-infant bonding process in a client. Which observation, if made by the nurse, indicates the potential for a maladaptive interaction?
1. The mother is observed talking to the newborn.
2. The mother performs cord care for the newborn.
3. The mother verbalizes discomfort with the new role of motherhood.
4. The mother requests that the nurse feed the newborn because she is feeling fatigued.

The postpartum nurse is caring for a woman who just delivered a healthy newborn. The nurse should be most concerned with the presence of subinvolution if which occurs?
1. The presence of afterpains
2. Retained placental fragments from delivery
3. An oral temperature of 99.0° F following delivery
4. Increased estrogen and progesterone levels as noted on laboratory analysis

The nurse is monitoring a postpartum client who is at risk of developing postpartum endometritis. Which finding, if noted during the first 24 hours after delivery, would support a diagnosis of postpartum endometritis?
1. Abdominal tenderness and chills
2. Increased perspiration and appetite
3. Maternal oral temperature of 100.2° F
4. Uterus two fingerbreadths below midline and firm

Which nursing intervention would be most appropriate for a postpartum client with a diagnosis of endometritis to facilitate participation in newborn care?
1. Limit fluid intake.
2. Maintain the client in a supine position.
3. Ask family members to care for the newborn.
4. Encourage the client to take pain medication as prescribed.

The nurse is caring for a client in the postpartum period immediately after delivery. The nurse performs an assessment on the client and prepares to assess uterine involution by taking which action?
1. Monitoring the vital signs
2. Palpating the uterine fundus
3. Auscultating the bowel sounds
4. Assessing the amount of drainage on the peripad

The nurse is assessing a client in the postpartum period and suspects the presence of uterine atony. Which is the initial nursing action?
1. Massage the uterus until firm.
2. Take the client's blood pressure.
3. Contact the health care provider (HCP).
4. Assess the amount of drainage on the peripad.

The postpartum unit nurse is developing a plan of care for a first-time mother and identifies the need for measures that will promote parent-infant bonding. Which measure should the nurse include in the plan?
1. Use a low-pitched voice to speak to the infant.
2. Encourage the mother to hold the infant when the infant cries.
3. Encourage the parents to allow the infant to sleep in the parental bed.
4. Encourage the mother to allow the nursing staff to care for the infant during her hospital stay until she is discharged.

The postpartum unit nurse has provided discharge instructions to a client planning to breast-feed her normal, healthy infant. Which statement by the client indicates an understanding of the instructions?
1. "If I experience any sweating during the night, I should call the health care provider."
2. "If I have uterine cramping while breast-feeding, I should contact the health care provider."
3. "If I'm still having bloody vaginal drainage in a week, I should contact the health care provider."
4. "If I notice any pain, redness, or swelling in my breasts, I should contact the health care provider."

A client arrives at the postpartum unit after delivery of her infant. On performing an assessment, the nurse notes that the client is shaking uncontrollably. Which nursing action would be appropriate?
1. Massage the fundus.
2. Contact the health care provider.
3. Cover the client with a warm blanket.
4. Place the client in Trendelenburg's position.

The postpartum unit nurse has provided information regarding performing a sitz bath to a new mother after a vaginal delivery. The client demonstrates understanding of the purpose of the sitz bath by stating that the sitz bath will promote which action?
1. Numb the tissue.
2. Stimulate a bowel movement.
3. Reduce the edema and swelling.
4. Assist in healing and provide comfort.

A nurse is assessing the fundus in a postpartum woman and notes that the uterus is soft and spongy and is not firmly contracted. The nurse should prepare to implement which interventions? Select all that apply.
1. Massaging the uterus
2. Pushing gently on the uterus
3. Assisting the woman to urinate
4. Rechecking the uterus in 1 hour
5. Checking for a distended bladder
6. Calling the delivery room to schedule an abdominal hysterectomy

A woman infected with the human immunodeficiency virus (HIV) has given birth to a normal-appearing infant, and the nurse provides instructions about newborn infant care. Which statement by the mother indicates a need for further instruction?
1. "I'm going to breast-feed my baby starting right away."
2. "I need to wash my hands before and after bathroom use."
3. "My baby needs to be on antiviral medications for the next 6 weeks."
4. "I am going to contact some support groups listed in my take-home material to help me with everything I'll have to deal with when I get home."

The clinic nurse is performing an assessment on a client who is 6 days postpartum. When assessing involution, the nurse expects the uterine fundus to be located at which area?

1. A
2. B
3. C
4. D

A client with known cardiac disease has been admitted to the postpartum care unit after an uneventful delivery. The unit nurse instructs the client to use the call button for assistance whenever she needs to get out of bed or wishes to care for her infant. Which postpartum complication is the nurse most concerned about for this client?
1. Postpartum infection
2. Maternal attachment
3. Maternal overexertion
4. Postpartum newborn-mother bonding

A postpartum care unit nurse is reviewing the records of 4 new mothers admitted to the unit. The nurse determines that which mother would be least likely at risk for developing a puerperal infection?
1. A mother who had ten vaginal exams during labor
2. A mother with a history of previous puerperal infections
3. A mother who gave birth vaginally to a 3200 gram infant
4. A mother who experienced prolonged rupture of the membranes

A postpartum unit nurse is preparing to care for a client who has just delivered a healthy newborn. In the immediate postpartum period what is the recommended frequency for the nurse to assess the client's vital signs?
1. Every hour for the first 2 hours and then every 4 hours
2. Every 30 minutes during the first hour and then every hour for the next 2 hours
3. Every 5 minutes for the first 30 minutes and then every hour for the next 4 hours
4. Every 15 minutes during the first hour and then every 30 minutes for the next 2 hours

The postpartum unit nurse is performing an assessment on a client who is at risk for thrombophlebitis. Which nursing action is indicated in assessing for thrombophlebitis?
1. Palpate for pedal pulses.
2. Ask the client about pain in the calf area.
3. Assess for the presence of vaginal hematoma.
4. Ask the client to ambulate and assess for the presence of pain.

The rubella vaccine is prescribed to be administered to a client 2 days after delivery of her child. The nurse preparing to administer the vaccine develops a list of the potential risks associated with this vaccine. The nurse reviews the list with the client and cautions the client to avoid which situation?
1. Sunlight for 3 days
2. Scratching the injection site
3. Pregnancy for 2 to 3 months after the vaccination
4. Sexual intercourse for 2 to 3 months after the vaccination

On the second postpartum day, a woman complains of burning on urination, urgency, and frequency of urination. A urinalysis is done, and the results indicate the presence of a urinary tract infection. The nurse instructs the new mother regarding measures to take for treatment of the infection. Which statement, if made by the mother, would indicate a need for further instructions?
1. "I need to urinate frequently throughout the day."
2. "The prescribed medication must be taken until it is finished."
3. "My fluid intake should be increased to at least 3000 mL daily."
4. "Foods and fluids that will increase urine alkalinity should be consumed."

A pregnant woman who is infected with the human immunodeficiency virus (HIV) delivers a newborn infant, and the nurse provides instructions to help the mother regarding care of the infant. Which statement by the client would indicate the need for further instructions? 
1. "I will be sure to wash my hands before and after bathroom use." 
2. "I need to breast-feed, especially for the first 6 weeks postpartum." 
3. "Support groups are available to assist me with understanding my diagnosis of HIV." 
4. "My newborn infant should be on antiviral medications for the first 6 weeks after delivery."

The home care nurse's assignment is to visit a new mother at home 24 to 48 hours after discharge. What should the nurse expect to note in a healthy mother who is breast-feeding her newborn infant?
1. The mother has cracked nipples and feeds the infant with a supplemental bottle.
2. The mother complains of breast engorgement, and the infant demonstrates difficulty in latching onto the breast.
3. The mother is breast-feeding the infant with the infant's head turned toward her breast and the body flat in her arms; the mother has sore nipples, and the infant has a suck blister.
4. The mother is breast-feeding with the infant in a tummy-to-tummy position without signs of cracked nipples; the baby demonstrates bursts of sucking, followed by a pause and swallow.

The nurse who is employed in a prenatal clinic is performing prenatal assessments on clients who are in their first trimester of pregnancy. The nurse is concerned with identifying clients who may be at risk for the development of postpartum complications. Which client would be at the lowest risk for development of postpartum thromboembolic disorders?
1. A 39-year-old woman who reports that she smokes
2. A 26-year-old woman with a family history of thrombophlebitis
3. A 37-year-old woman in her fourth pregnancy who is overweight
4. A 22-year-old woman with a first pregnancy who states that oral contraceptives taken in the past have caused thrombophlebitis

The nurse has provided instructions for a postpartum client at risk for thrombosis regarding measures to prevent its occurrence. Which statement, if made by the client, indicates a need for further education?
1. "I should apply my antiembolism stockings after breakfast."
2. "I should avoid prolonged standing or sitting in one position."
3. "I should perform regularly scheduled exercise such as walking."
4. "I should avoid using pillows under my knees to prevent pressure in the back of my knee area."

The discharge nurse is discussing mastitis with a postpartum client. Which statement made by the client indicates a need for further instruction?
1. "If I develop a hot, reddened, triangle-shaped area on my breast, I should contact my health care provider."
2. "Antibiotics, rest, warm compresses, and adequate fluid intake are all important for the treatment of mastitis."
3. "If I develop a fever, chills, or body aches at any time after discharge, I should stop breast-feeding immediately."
4. "I may develop mastitis if I wear underwire bras, experience excessive fatigue, or suddenly decrease the number of feedings."

On assessment of a client who is 30 minutes into the fourth stage of labor, the nurse finds the client's perineal pad saturated in blood and blood soaked into the bed linen under the client's buttocks. Which is the nurse's initial action?
1. Call the health care provider.
2. Assess the client's vital signs.
3. Gently message the uterine fundus.
4. Administer a 300-mL bolus of a 20 units/L oxytocin (Pitocin) solution.

After receiving report at the beginning of the 0700 shift, the nurse must decide in what order the clients should be assessed. How would the nurse plan assessments? Arrange the clients in the order that they should be assessed. All options must be used.
1. An 8-hour post–vaginal delivery gravida 2, para 2 client who is scheduled for a bilateral tubal ligation at 1200 today and has a continuous peripheral intravenous (IV) solution of 5% dextrose in lactated Ringer's solution (D5LR) with 20 milliunits of oxytocin (Pitocin) infusing at 125 mL/hr.
2. A 12-hour post–cesarean section delivery of a gravida 3, para 3, who reports a return of feeling in her lower extremities as well as a sensation of wetness underneath her buttocks.
3. A 48-hour post–cesarean section delivery of a gravida 1, para 1, who reports not yet having a bowel movement since delivery and requests a stool softener.
4. A 24-hour post–vaginal delivery of a gravida 4, para 4, who is complaining of abdominal cramping after nursing her baby and requesting ibuprofen (Motrin).

A client who is a gravida III, para III had a cesarean section 1 day ago. She is being treated prophylactically for endometritis. She is complaining of abdominal cramping at a level of 6 on pain level scale of 1 to 10 (with 10 being the greatest amount of pain) and fears having her first bowel movement. These medications are prescribed and due now. Based on priority, in which order should the nurse administer the medications? Arrange the medications in the order that they should be administered. All options must be used.
1. Prenatal vitamin 1 tablet orally daily
2. Docusate sodium (Colace) 100 mg orally
3. Ketorolac (Toradol) 30 mg by intravenous push over 3 minutes
4. Ampicillin sodium (Ampicillin) 1 g intravenous (IV) piggyback over 60 minutes

A nurse is checking lochia discharge in a woman in the immediate postpartum period. The nurse notes that the lochia is bright red and contains some small clots. Based on this data, the nurse should make which interpretation?
1. The client is hemorrhaging.
2. The client needs to increase oral fluids.
3. The client is experiencing normal lochia discharge.
4. The client's health care provider needs to be notified of the finding.

A postpartum woman with mastitis in the right breast complains that the breast is too sore for her to breast-feed her infant. The nurse should tell the client to implement which measure?
1. Pump both breasts and discard the milk.
2. Bottle-feed the infant on a temporary basis.
3. Breast-feed from the left breast and gently pump the right breast.
4. Stop breast-feeding from both breasts until this condition resolves.

The rubella vaccine has been prescribed for a new mother. Which statement should the postpartum nurse make when providing information about the vaccine to the client?
1. "You will need a second vaccination at your 6-week postpartum visit."
2. "You should avoid sexual intercourse for 2 weeks after the administration of the vaccine."
3. "You should not become pregnant for 1 to 3 months after the administration of the vaccine."
4. "You should avoid heat and extreme temperature changes for a week after the administration of the vaccine."

A nurse has just received an intershift report. After reviewing the client assignment and the appropriate medical records, the nurse determines that which client is most at risk for developing postdelivery endometritis?
1. A primigravida with a normal spontaneous vaginal delivery
2. A gravida II who delivered vaginally following an 18-hour labor
3. A client experiencing an elective cesarean delivery at 38 weeks' gestation
4. An adolescent experiencing an emergency cesarean delivery for fetal distress

A nurse provides a list of discharge instructions to a client who has delivered a healthy newborn by cesarean delivery. Which statement by the client indicates the need for further teaching?
1. "I can begin abdominal exercises immediately."
2. "I need to notify the health care provider if I develop a fever."
3. "I can't lift anything heavier than my newborn for at least 2 weeks."
4. "I need to turn on my side and push up with my arms to get out of bed."

A nurse is caring for a client who has just delivered a newborn following a pregnancy with a placenta previa. When reviewing the plan of care, the nurse should prepare to monitor the client for which risk that is associated with placenta previa?
1. Infection
2. Hemorrhage
3. Chronic hypertension
4. Disseminated intravascular coagulation

The nurse is preparing to perform a fundal assessment on a postpartum client. The nurse understands that which is the initial nursing action when performing this assessment?
1. Ask the client to turn on her side.
2. Ask the client to urinate and empty her bladder.
3. Massage the fundus gently before determining the level of the fundus.
4. Ask the client to lie flat on her back, with her knees and legs flat and straight.

The nurse is preparing to care for a client in the immediate postpartum period who has just delivered a healthy newborn. How often should the nurse plan to take the client's vital signs?
1. Hourly for the first 2 hours and then every 4 hours
2. 30 minutes during the first hour and then every hour for the next 2 hours
3. 5 minutes for the first 30 minutes and then every hour for the next 4 hours
4. 15 minutes during the first hour and then every 30 minutes for the next 2 hours

The nurse is providing nutritional counseling to a new mother who is breast-feeding her newborn. The nurse should instruct the client that her calorie needs should increase by approximately how many calories a day?
1. 100
2. 300
3. 500
4. 1000

The postpartum client asks the nurse about the occurrence of afterpains. The nurse informs the client that afterpains will be especially noticeable during which activity?
1. Ambulating
2. Breast-feeding
3. Taking sitz baths
4. Arriving home and activities are increased

The nursing instructor is reviewing the plan of care with a student regarding care of a postpartum client. The instructor asks the nursing student about the taking-in phase according to Rubin's phases of regeneration and the client behaviors that are most likely to occur during this phase. Which response made by the student indicates an understanding of this phase?
1. "The client would be independent."
2. "The client initiates activities on her own."
3. "The client participates in mothering tasks."
4. "The client is self-focused and talks to others about labor."

The nurse is teaching a new mother how to care for her newborn. The nurse notes that the client is very fearful and reluctant to handle the newborn and notes that this is the client's first child. Which nursing intervention is least appropriate in assisting the promotion of mother-infant interaction and bonding?
1. Accepting the client's feelings
2. Acknowledging the client's apprehension
3. Assisting the client with giving the baths to allow her to become more at ease
4. Leaving the infant with the client so that she will be required to provide the care

The nurse is assigned to care for a client who has chosen to formula-feed her infant. The nurse should plan to provide which instruction to the client?
1. Apply a heating pad to breasts for comfort.
2. Wear a breast shield to correct nipple inversion.
3. Wear a supportive brassiere continuously for 72 hours.
4. Use the manual breast pump provided to express milk.

The postpartum client who had a vaginal delivery of a healthy newborn has a prescription for a sitz bath. The nurse should tell the client that the sitz bath will provide which effect?
1. Numb the tissue.
2. Stimulate a bowel movement.
3. Reduce the edema and swelling.
4. Promote healing and provide comfort.

A nurse is monitoring a new mother in the fourth stage of labor for signs of hemorrhage. Which indicates an early sign of excessive blood loss?
1. A temperature of 100.4º F
2. An increased pulse rate of 88 to 102 beats/min
3. A blood pressure change from 130/88 to 124/80 mm Hg
4. An increase in the respiratory rate from 18 to 22 breaths/min

A nurse is providing instructions to a client who has been diagnosed with mastitis. Which statement made by the client indicates a need for further teaching?
1. "I need to wear a supportive bra to relieve the discomfort."
2. "I need to stop breast-feeding until this condition resolves."
3. "I can use analgesics to assist in alleviating some of the discomfort."
4. "I need to take antibiotics, and I should begin to feel better in 24 to 48 hours."

A nurse is monitoring the client for signs of postpartum depression. Which would indicate the need for further assessment related to this form of depression?
1. The client is caring for the infant in a loving manner.
2. The client demonstrates an interest in the surroundings.
3. The client constantly complains of tiredness and fatigue.
4. The client looks forward to visits from the father of the newborn.

The nurse caring for a client with a diagnosis of subinvolution should understand that which is a primary cause of this diagnosis?
1. Afterpains
2. Increased estrogen levels
3. Increased progesterone levels
4. Retained placental fragments from delivery

The nurse has determined that a postpartum client has physical findings consistent with uterine atony. The nurse should plan to take which action first?
1. Massage the uterus until firm.
2. Take the client's blood pressure.
3. Ask the client about the presence of pain.
4. Recheck the amount of drainage on the peripad.

When planning care for a postpartum client that plans to breast-feed her infant, which important piece of information should the nurse include in the teaching plan to prevent the development of mastitis?
1. Offer only one breast at each feeding.
2. Massage distended areas as the infant nurses.
3. Cleanse nipples with a mild antibacterial soap before and after infant feedings.
4. Express and discard milk from the affected breast at the first signs of mastitis.

Which instructions should a nurse provide to a client following delivery regarding care of the episiotomy site to prevent infection? Select all that apply.
1. Report a foul-smelling discharge.
2. Take a warm sitz baths three times a day.
3. Change the perineum pads three times a day.
4. Use warm water to rinse the perineum after elimination.
5. Wipe the perineum from front to back after voiding and defecation.

A nurse visits a client at home who delivered a healthy newborn 2 days ago. The client is complaining of breast discomfort. The nurse notes that the client is experiencing breast engorgement. Which instructions should the nurse provide to the client regarding relief of the engorgement? Select all that apply.
1. Wear a supportive bra between feedings.
2. Avoid breast-feeding during the time of breast engorgement.
3. Feed the infant at least every 2 hours for 15 to 20 minutes on each side.
4. Apply moist heat to both breasts for about 20 minutes before a feeding.
5. Massage the breasts gently during a feeding, from the outer areas to the nipples.

On the second postpartum day, a client complains of burning, urgency, and frequency of urination. A urinalysis is obtained, and the results indicate the presence of a urinary tract infection. Which measures should the nurse instruct the client to take regarding the prevention and treatment of the infection? Select all that apply.
1. Urinate frequently throughout the day.
2. Wipe the perineal area from front to back after urinating.
3. Fluid intake should be increased to at least 3000 mL/day.
4. Prescribed medication must be taken until it is completed.
5. Foods and fluids that will increase urine alkalinity should be consumed.