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Terms in this set (28)
During a home visit, the nurse assesses a client 2 weeks after delivery. Which of the following signs/symptoms should the nurse expect to see?
Diaphoresis
Lochia alba
Cracked nipples
Hypertension
Lochia alba
A breast feeding client, G10P6408,
delivered 10 minutes ago. Which of the following assessments is most important for the nurse to perform.
Pulse
Fundus
Bladder
breast
Fundus
The nurse is performing a postpartum assessment on a client who delivered 4 hours ago. The nurse notes a boggy fundus at the umbilicus with heavy lochial flow. Which of the following nursing actions is appropriate?
Massage the fundus
Notify the
obstetrician
Administer oxytocin
Assist the client to the bathroom
Massage the fundus
Which symptom would the nurse expect to observe in a postpartum client with a vaginal hematoma?
1. Pain
2. Bleeding
3. Warmth
4. Redness
Pain
A nurse who is called to a client's room notes that the client's cesarean incision
has separated. Which of the following actions is the highest priority for the nurse to perform?
Cover the wound with sterile wet dressing
Notify the surgeon
Elevate the head of the bed
Flex the client's knees
Notify the surgeon
A woman is menstruating. If hormonal studies were to be done at this time, which of the following hormonal levels would the nurse expect to see?
Both estrogen and
progesterone high
Estrogen is high and progesterone is low
Estrogen is low and progesterone is high
Both estrogen and progesterone are low
Both estrogen and progesterone are low
What is the hormone responsible for ovulation?
LH
What organs does the placenta replace?
Lungs, kidneys, liver, GI tract replaced by placenta
A woman comes into the office and states that her LMP was August 3rd. When would you tell her she might be due.
August 3rd -3 months + 7 days, would be May 10th estimated due date
A women who is A- delivers a baby who is AB-. Will she receive a Rhogam shot after delivery? Why?
Shes does not need it because
Ms. Z. has a 5-year old child who was full-term at birth. Since that time she has had an infant who was stillborn at 38 weeks and a spontaneous abortion that occurred at 13 weeks. She is currently 7 months pregnant.
Ms. Z
G4T2P0A1L1
Child term at birth goes to G, T, L
Stillborn at 38 weeks goes 1 to G, 1 to T and 1 to A
Abortion BEFORE age of viability (20-36), 1 to G, 1 to A
Ms. M. has had 3 pregnancies and is pregnant again. (At home, she has full-term twins and a child born at 36 weeks.) She also has had a fetus that spontaneously aborted at 10 weeks.
Ms. M
G4T2P1A1L3
36 weeks is preterm! After 36 weeks it term
The nurse is performing a postpartum assessment on a client who delivered 4 hours ago. The nurse notes a firm fundus at the
umbilicus with heavy lochial flow. Which of the following nursing actions is appropriate?
Massage the fundus
Notify the obstetrician
Administer oxytocin
Assist the client to the bathroom
Notify Obstetrician
To prevent infection, the nurse teaches the postpartum client to perform which of the following tasks?
Apply antibiotic ointment to the perineum daily
Change the peripad at each
voiding
Void at least every 2 hours
Spray the perineum with a providone-iodine solution after toileting
Change the peripad
A client is 40 minutes postpartum from a forceps delivery of a 4500 gram neonate over a right mediolateral episiotomy. The client is at risk for each of the follow nursing diagnoses. Which of the diagnoses is highest priority at this time?
Ineffective breast feeding
Fluid
Volume Deficit
Infection
Pain
Fluid volume deficit
A woman's temperature has just risen 0.4 degrees F and will remain elevated for the remainder of her cycle. What hormone is responsible for the temperature elevation?
Estrogen
Progesterone
LH
FSH
Progesterone
What does the hormone hPL do?
Glucose resistance
Until the placenta is mature enough to take over the production of estrogen and progesterone, what part of the body continues to produce them when pregnant?
Corpus luteum
A women comes into the OB/GYN office you are working at as a nurse. She is visibly pregnant and this is her first appointment. What are ways you could use to determine her due date?
McDonanlds
Which of the following findings would the nurse determine are presumptive signs of pregnancy?
Amenorrhea
Breast tenderness
Quickening
Frequent urination
Uterine growth
Amenorrhea, Breast tenderness, quickening, frequent urination
A women has a family history of Tay-sachs and
wants to know if her baby could be born with the disease. What is the earliest test that could be done to determine this?
CVS
Amniocentesis
MSAFP
Ultrasound
CVS
4 ts with PPH
Tone
Tissue
Trauma
Thrombin
A 3-day postpartum client, who is not immune to rubella, is to receive the vaccine at discharge. Which of
the following must the nurse include in her discharge teaching regarding the vaccine?
1. The woman should not become pregnant for at least 4 weeks.
2. The woman should pump and dump her breast milk for 1 week.
3. The mother must wear a surgical mask when she cares for the baby.
4. Passive antibodies transported across the placenta will protect the baby.
1
The nurse is evaluating the involution of a
woman who is 3 days postpartum. Which of the following findings would the nurse evaluate as normal?
1. Fundus 1 cm above the umbilicus, lochia rosa.
2. Fundus 2 cm above the umbilicus, lochia alba.
3. Fundus 2 cm below the umbilicus, lochia rubra.
4. Fundus 3 cm below the umbilicus, lochia serosa.
The fundus 3cm below the umbilicus, lochia serosa
The day after delivery a woman, whose fundus is firm
at 1 cm below the umbilicus and who has moderate lochia, tells the nurse that something must be wrong, "All I do is go to the bathroom." Which of the following is an appropriate nursing response?
1. Catheterize the client per doctor's orders.
2. Measure the client's next voiding.
3. Inform the client that polyuria is normal.
4. Check the specific gravity of the next voiding.
3.
The nurse is caring
for a postpartum client who experienced a second-degree perineal laceration at delivery 2 hours ago. Which of the following interventions should the nurse perform at this time?
1. Apply an ice pack to the perineum.
2. Advise the woman to use a sitz bath after every voiding.
3. Advise the woman to sit on a pillow.
4. Teach the woman to insert nothing into her rectum.
1.
A nurse is assessing the fundus
of a client during the immediate postpartum period. Which of the following actions indicates that the nurse is performing the skill correctly?
1. The nurse measures the fundal height using a paper centimeter tape.
2. The nurse stabilizes the base of the uterus with his or her dependent hand.
3. The nurse palpates the fundus with the tips of his or her fingers.
4. The nurse precedes the assessment with a sterile vaginal exam.
2
Which of the following is the priority nursing action during the immediate postpartum period?
1. Palpate fundus.
2. Check pain level.
3. Perform pericare.
4. Assess breasts.
1
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