Chapter 10: Nursing Care of Women With Complications Following Birth My Nursing Test Banks

Chapter 10: Nursing Care of Women With Complications Following Birth

Elsevier items and derived items 2007 by Saunders, an imprint of Elsevier Inc.

MULTIPLE CHOICE

1. The first sign of hypovolemic shock from postpartum hemorrhage is likely to be:

a.

Cold, clammy skin

b.

Tachycardia

c.

Hypotension

d.

Decreased urinary output

ANS: B

Tachycardia is usually the first sign of inadequate blood volume.

DIF: Cognitive Level: Knowledge REF: Text Reference: 237

OBJ: Objective: 2 TOP: Topic: Hemorrhage

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. Although the nurse has massaged the uterus every 15 minutes, the uterus remains flaccid and the patient continues to pass large clots. The nurse recognizes these signs as indicating:

a.

Uterine atony

b.

Uterine dystocia

c.

Uterine hypoplasia

d.

Uterine dysfunction

ANS: A

Atony describes a lack of normal muscle tone. If the uterus is atonic, then muscle fibers are flaccid and will not compress bleeding vessels.

DIF: Cognitive Level: Knowledge REF: Text Reference: 237

OBJ: Objective: 2 TOP: Topic: Early Postpartum Hemorrhage

KEY: Nursing Process Step: N/A

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

3. The nurses first action when postpartum hemorrhage from uterine atony is suspected is to:

a.

Teach the patient how to massage the abdomen and then get help

b.

Start IV fluids to prevent hypovolemia, then notify the registered nurse

c.

Begin massaging the fundus while another person notifies the physician

d.

Ask the patient to void and reassess fundal tone and location

ANS: C

When the uterus is boggy, the nurse should immediately massage it until it becomes firm.

DIF: Cognitive Level: Comprehension REF: Text Reference: 238

OBJ: Objective: 6 TOP: Topic: Early Postpartum Hemorrhage

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

4. The nurse assesses a boggy uterus with the fundus above the umbilicus and deviated to the side. The nurse should next assess:

a.

Fullness of the bladder

b.

Amount of lochia

c.

Blood pressure

d.

Level of pain

ANS: A

Bladder distention can cause uterine atony. The uterus is massaged to firmness and then the bladder is emptied.

DIF: Cognitive Level: Application REF: Text Reference: 240

OBJ: Objective: 6 TOP: Topic: Early Postpartum Hemorrhage

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

5. If massage and putting the baby to breast is not effective in controlling a boggy uterus, the nurse explains that the physician may order:

a.

Ritodrine

b.

Magnesium sulfate

c.

Pitocin

d.

Parlodel

ANS: C

Pitocin is the most common drug ordered to control uterine atony.

DIF: Cognitive Level: Comprehension REF: Text Reference: 241

OBJ: Objective: 5 TOP: Topic: Early Postpartum Hemorrhage

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

6. When the 4-week postpartum patient with mastitis asks the nurse if she can continue to breastfeed, the nurses most helpful response is:

a.

Stop breastfeeding until the infection clears.

b.

Pump the breasts to continue milk production, but do not give breast milk to the infant.

c.

Begin all feedings with the affected breast until the mastitis is resolved.

d.

Breastfeeding can continue unless there is any abscess formation.

ANS: D

The woman with mastitis can continue to breastfeed unless an abscess forms.

DIF: Cognitive Level: Application REF: Text Reference: 244

OBJ: Objective: 6 TOP: Topic: Mastitis and Breastfeeding

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

7. A woman had a vaginal delivery two days ago and is preparing for discharge. To help prevent postpartum complications, the nurse plans to teach the woman to report any:

a.

Fever

b.

Change in lochia from red to white

c.

Contractions

d.

Fatigue and irritability

ANS: A

Increased temperature is a sign of infection. The other choices are normal in the postpartum period.

DIF: Cognitive Level: Application REF: Text Reference: 243

OBJ: Objective: 6 TOP: Topic: Puerperal Infections

KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

8. One day after discharge the postpartum patient calls the clinic complaining of a reddened area on her lower leg, a temperature elevation of 99.8F, a rust-colored lochia, and sore breasts. From these symptoms, the nurse suspects:

a.

Phlebitis

b.

Puerperal infection

c.

Late postpartum hemorrhage

d.

Mastitis

ANS: A

The complaints related to the leg are indicative of phlebitis. The other signs are normal in the postpartum client.

DIF: Cognitive Level: Application REF: Text Reference: 242

OBJ: Objective: 4 TOP: Topic: Phlebitis

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

9. The statement that would indicate to the nurse on a postpartum home visit that the patient understands the signs of late postpartum hemorrhage is:

a.

My discharge would change to red after it has been pink or white.

b.

If I have a postpartum hemorrhage, I will have severe abdominal pain.

c.

I should be alert for an increase in my lochia alba.

d.

I would pass a large clot that was retained from the placenta.

ANS: A

When the nurse teaches the postpartum woman about normal changes in lochia, it is important to explain that a return to red bleeding after it has changed to pink or white may indicate a late postpartum hemorrhage.

DIF: Cognitive Level: Application REF: Text Reference: 241

OBJ: Objective: 2 TOP: Topic: Late Postpartum Hemorrhage

KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

10. During a postpartum assessment, a woman reports that her right calf is painful. The nurse observes edema and redness along the saphenous vein in the right lower leg. Based on this finding, the nurse explains that the probable treatment will involve:

a.

Anticoagulants for 6 weeks

b.

Application of ice to the affected leg

c.

Gentle massage of the affected leg

d.

Passive leg exercises twice a day

ANS: A

Anticoagulant therapy is continued with heparin or Coumadin for 6 weeks after birth to minimize the risk of embolism.

DIF: Cognitive Level: Analysis REF: Text Reference: 242

OBJ: Objective: 5 TOP: Topic: Thromboembolic Disorders

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

11. The nurse determines that a woman with mastitis understands treatment instructions when she says:

a.

Apply cold compresses to the painful areas.

b.

Take a warm shower before nursing the baby.

c.

Nurse first on the affected side.

d.

Empty the affected breast every 8 hours.

ANS: B

Moist heat promotes blood flow to the area, comfort, and complete emptying of the breast.

DIF: Cognitive Level: Analysis REF: Text Reference: 244

OBJ: Objective: 6 TOP: Topic: Mastitis

KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

12. The best response to a postpartum woman who tells the nurse that she feels tired and sick all of the time since I had the baby 3 months ago is:

a.

This is a normal response for the body after pregnancy. Try to get more rest.

b.

Ill bet you will snap out of this funk real soon.

c.

Why dont you arrange for a babysitter so you and your husband can have a night out?

d.

Lets talk about this further. I am concerned about how you are feeling.

ANS: D

If a postpartum woman seems depressed, it is important to explore her feelings to determine if they are persistent and pervasive.

DIF: Cognitive Level: Application REF: Text Reference: 246

OBJ: Objective: 6 TOP: Topic: Disorders of Mood

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

13. The nurse is caring for a woman who had a cesarean birth yesterday. Varicose veins are visible on both legs. To prevent thrombus formation the nurse would:

a.

Have the woman sit in a chair for meals.

b.

Monitor vital signs every 4 hours and report any changes.

c.

Tell the woman to remain in bed with her legs elevated.

d.

Assist the woman with ambulation for short periods of time.

ANS: D

Early ambulation and range-of-motion exercises are valuable aids to preventing thrombus formation in the postpartum woman.

DIF: Cognitive Level: Application REF: Text Reference: 242

OBJ: Objective: 4 TOP: Topic: Thromboembolic Disorders

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

14. Five days after a spontaneous vaginal delivery, a woman comes to the emergency room because she has a fever and persistent cramping. The nurse recognizes that the cause of these signs and symptoms may be:

a.

Dehydration

b.

Hypovolemic shock

c.

Endometritis

d.

Cystitis

ANS: C

Fever after 24 hours following delivery is suggestive of an infection. Severe cramping and fever are manifestations of endometritis.

DIF: Cognitive Level: Analysis REF: Text Reference: 243

OBJ: Objective: 2 TOP: Topic: Puerperal Infections

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

15. At her 6-week postpartum checkup, a woman mentions to the nurse that she cant sleep and she is not eating. She feels guilty because sometimes she wishes her baby would die. The nurse recognizes this womans symptoms as:

a.

Bipolar disorder

b.

Major depression

c.

Postpartum blues

d.

Postpartum depression

ANS: B

Major depression is a disorder characterized by deep feelings of worthlessness, guilt, serious sleep and appetite disturbances, and sometimes delusions about the infant being dead.

DIF: Cognitive Level: Analysis REF: Text Reference: 247

OBJ: Objective: 2 TOP: Topic: Disorders of Mood

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

16. Three weeks after delivering her first child, a woman tells the nurse, I waited so long for this baby and now that she is here, I cant believe how different my life is from what I expected. The best nursing response to the womans statement is:

a.

How is your partner adjusting to the change?

b.

I hear this from a lot of first-time mothers.

c.

Have you told anyone else about your feelings?

d.

Tell me how things are different.

ANS: D

The nurse may help the woman by being a sympathetic listener. The nurse should elicit the new mothers feelings about motherhood and her infant.

DIF: Cognitive Level: Application REF: Text Reference: 247

OBJ: Objective: 2 TOP: Topic: Disorders of Mood

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

17. After a prolonged labor, a woman vaginally delivered a 10 pound, 3 ounce baby boy. In the immediate postpartum period, the nurse would be alert for the development of:

a.

Cervical laceration

b.

Hematoma

c.

Endometritis

d.

Retained placental fragments

ANS: B

Delivering a large infant and a prolonged labor are risk factors for hematoma formation.

DIF: Cognitive Level: Analysis REF: Text Reference: 241

OBJ: Objective: 3

TOP: Topic: Early Postpartum Hemorrhage-Hematoma

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

18. A woman has had persistent lochia rubra for two weeks since her delivery and is experiencing pelvic discomfort. When subinvolution is diagnosed, the nurse explains that the usual treatment for this disorder is:

a.

Uterine massage

b.

Pitocin infusion

c.

Dilation and curettage

d.

Hysterectomy

ANS: C

Medical treatment for subinvolution is selected to correct the cause. Treatment may include dilation of the cervix and curettage to remove retained placental fragments from the uterine wall.

DIF: Cognitive Level: Knowledge REF: Text Reference: 245

OBJ: Objective: 5 TOP: Topic: Subinvolution of the Uterus

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

19. The 1-day postpartum patient shows a temperature elevation, cough, and slight shortness of breath on exertion. Based on these symptoms the nurse should:

a.

Notify the charge nurse of a possible upper respiratory infection

b.

Notify the physician of a possible pulmonary embolism

c.

Document expected postpartum mucous membrane congestion

d.

Medicate with antipyretic remedy for elevated temperature

ANS: B

Symptoms of early pulmonary embolism may not be dynamic. The cough with shortness of breath and temperature elevation is a clue to this possible complication.

DIF: Cognitive Level: Application REF: Text Reference: 245

OBJ: Objective: 5 TOP: Topic: Pulmonary Embolus

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health promotion and Maintenance: Prevention and Early Detection of Disease

MULTIPLE RESPONSE

1. The nurse conducting a childbirth preparation class warns the patients that shock is a real threat after delivery due to:

Select all that apply.

a.

Pulmonary embolism

b.

Blood clotting disorders

c.

Anemia

d.

Infection

e.

Postpartum hemorrhage

ANS: A, B, C, D, E

All the options may be the cause of postpartum shock.

DIF: Cognitive Level: Application REF: Text Reference: 236

OBJ: Objective: 5 TOP: Topic: Postpartum Shock

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

2. When the nurse assesses the perineal pad placed on a 3-hour postdelivery patient and finds that there is no lochia on it, the nurse would expect to find on further assessment:

Select all that apply.

a.

A firm fundus the size of a grapefruit

b.

A full and turgid bladder

c.

Retained placental fragments

d.

Vital signs indicative of shock

e.

A soft boggy fundus

ANS: B, E

Large clots that form in a flaccid uterus can obstruct the flow of lochia. A full bladder is a major cause of a uterus that is boggy.

DIF: Cognitive Level: Analysis REF: Text Reference: 239

OBJ: Objective: 4 TOP: Topic: Large Clots

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

3. When the nurse flexes the patients leg and dorsiflexes the foot, the nurse is:

Select all that apply.

a.

Assessing for edema in the lower limb

b.

Performing range of motion exercises

c.

Stimulating circulation to limbs

d.

Assessing for deep vein thrombus

e.

Comparing color and temperature of the limbs

ANS: D

Performing the maneuver for Homans is an assessment for DVT.

DIF: Cognitive Level: Application REF: Text Reference: 242

OBJ: Objective: 7 TOP: Topic: Homans Sign

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

4. The nurse instructs the postpartum patient that her nutritional intake should include foods which are particularly supportive to healing, such as:

Select all that apply.

a.

Legumes

b.

Potatoes and pasta

c.

Citrus fruits

d.

Rice

e.

Cantaloupe

ANS: A, B, E

Legumes and foods containing Vitamin C are conducive to healing. Starches are not.

DIF: Cognitive Level: Application REF: Text Reference: 244

OBJ: Objective: 4 TOP: Topic: Foods Conducive to Healing

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

5. In order to reduce the risk of mastitis, the nurse will teach a nursing mother to:

Select all that apply.

a.

Limit fluid intake to 1 liter per day

b.

Empty both breasts with each feeding

c.

Take warm showers

d.

Wear a supportive bra

e.

Pump breasts to ensure emptying

ANS: B, C, D, E

Nursing mother should take in about 3 liters of fluid a day. All other options are interventions to reduce the risk of mastitis and milk accumulation in the breast.

DIF: Cognitive Level: Application REF: Text Reference: 244

OBJ: Objective: 4 TOP: Topic: Reduction of the Risk of Mastitis

KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

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