Question 5391)
The day after delivery, a new mother asks why her milk is so creamy and yellow.
What is the best response for the nurse to make?
A. “I wouldn’t worry about it.”
B. “This is normal. It will soon turn to real milk.”
C. “You’re coming along fine.”
D. “You haven’t gotten your milk in yet.”
Answer: B
Explanation: The client is describing colostrum. Milk comes in about 72 hours after delivery. Answers 1 and 3 do not
address the question asked by the mother. Answer 4 is technically accurate but does not give as much information
and reassurance as answer 2.
Question 5392)
A new mother is in the first period of adjustment following birth called the takingin phase. What type of maternal behavior would the nurse expect her to exhibit?
A. Passivity and dependence
B. Preoccupation with baby’s needs
C. Independence
D. Resuming control of life
Answer: B
Explanation: The taking in period is characterized by passivity and dependence. The mother relives her labor and
integrates it into her being. Preoccupation with the baby’s needs and reasserting independence are characteristic
of the taking hold phase, which follows the taking in phase. Resuming control of life is characteristic of the letting
go phase.
Question 5393)
A new mother has decided not to breastfeed her baby. Which statement indicates
the best understanding of the management of engorgement?
A. “I will stand with my back to the shower.”
B. “I will take a sitz bath every day.”
C. “I will apply a warm compress to my breasts three times a day.”
D. “I will drink a lot of liquids for the next few days.”
Answer: A
Explanation: Standing with her back to the shower will keep the warm water from stimulating milk production. Cool
compresses will help with engorgement; warm compresses stimulate milk flow. A sitz bath is indicated for an
episiotomy. It is not related to the care of the breasts. Consumption of excess fluids will encourage milk
production. Some additional fluids are necessary during the diaphoresis/diuresis phase after delivery.
Question 5394)
A new mother is about to be discharged from the hospital. Which statement made
by a new mother indicates a need for more instruction?
A. “I will use my old diaphragm for contraception.”
B. “I have an appointment for my six-week checkup.”
C. “My mother will be helping me with the children for the next two weeks.”
D. “I plan to go back to my job as a secretary in six weeks.”
Answer: A
Explanation: A woman should be resized for a diaphragm after the birth of a baby. The old one may no longer be
the correct size. The resizing will occur after involution is completed, usually at her sixweek checkup. If sexual
activity is resumed before that time, another means of contraception (such as the condom) should be used if she
does not wish to get pregnant. All of the other responses indicate understanding of postpartum care.
Question 5395)
A woman who delivered today by cesarean delivery asks the nurse, “How come my
baby has such a round head? My other baby’s head was not so round, and she was more red.”
What is the best response for the nurse to make?
A. “Each baby is different. It is not a good idea to compare your children.”
B. “Were forceps used when your older child was delivered?”
C. “Babies born by cesarean have rounder heads because they do not go through the birth canal.”
D. “A round head is a sign the baby is very intelligent. Your child should do very well in school.”
Answer: C
Explanation: Babies born by cesarean delivery do not have molded heads because they have not passed through the
pelvis and the birth canal. The other responses are not helpful. Answer 1 does not address the question. Forceps
can cause distinctive marks on the head. A round head is not a sign of intelligence.
Question 5396)
The nurse is caring for a woman who delivered a healthy infant via cesarean
delivery 30 minutes ago. The mother says to the nurse, “Please don’t touch my belly. I had an
operation.” What is the nurse’s best response?
A. “Alright I won’t. Be sure to let me know if you have any pain or bleeding.”
B. “I do need to look at your abdomen to check your incision.”
C. “I must touch your abdomen to check you uterus, but I won’t touch your incision.”
D. “I can wait two more hours before I will need to check your uterus.”
Answer: C
Explanation: A woman who had a cesarean delivery still needs to have the uterine fundus checked for firmness and
massaged if it is not firm. This is usually done every 15 minutes for the first two hours after delivery. The uterine
fundus is well above the incision site, so it is not necessary to touch the incision. The nurse should inspect the
dressing for bleeding.
Question 5397)
A woman is admitted to the postpartum unit two hours after delivery of a baby.
What action is especially important because the membranes were ruptured for 28 hours before
delivery?
A. Monitor her temperature every two hours
B. Provide perineal care with Zephiran every four hours
C. Maintain a strict perineal pad count
D. Have the mother take a sitz bath four times a day
Answer: A
Explanation: Temperature over 100.4°F after the second day usually indicates infection. Infection is the most
frequent maternal complication after prolonged rupture of the membranes. Zephiran perineal care is not a current
practice and is not related to prolonged rupture of the membranes. A strict perineal pad count is not necessary.
Sitz baths are a comfort measure for a sore perineum and are not related to prolonged rupture of the membranes.
Question 5398)
The nurse is caring for a woman who delivered a baby three hours ago. The
woman pulls the emergency call light and says she is bleeding all over the bed. The nurse enters
the room and sees the blood-soaked bed. What is the best initial action for the nurse to take?
A. Assess and massage the fundus if soft
B. Take vital signs
C. Place the client in sharp Trendelenburg position
D. Notify the physician immediately
Answer: A
Explanation: The most common cause of postpartum hemorrhage is uterine atony. Always assess the fundus first
and massage it if it is not firm. Taking vital signs and notifying the physician will be done after the nurse assesses
and massages the fundus if necessary. The client will not be placed in the Trendelenburg position.
Question 5399)
Methergine 5 mg qid is ordered for a postpartum client. An hour after taking the
drug, the woman complains of uterine cramping. What is the best explanation for the nurse to give
her?
A. “This is an unfortunate side effect, but you need the medicine.”
B. “The cramping is uncomfortable, but it is a sign that the drug is keeping your uterus contracted so you won’t bleed
too much.”
C. “Since you are experiencing cramps, I’ll ask the doctor to discontinue the drug.”
D. “The cramping should decrease soon. If it does not, let me know. I’ll see if the doctor will decrease the dosage.”
Answer: B
Explanation: This response explains the drug’s action to the client. Methergine is an oxytocic drug that helps the
uterus to contract and prevents postpartum bleeding. Answer 1 is not correct because it does not give the mother
the information she needs to understand why she is cramping. Answers 3 and 4 are not accurate.
Question 5400)
The nurse is caring for a woman who had a postpartum hemorrhage. Which of the
following facts about her delivery most likely contributed to her hemorrhage?
A. The baby weighed 10 lb 6 oz.
B. She received Pitocin after delivery of the placenta.
C. She delivered 10 days after her due date
D. Her second stage of labor lasted an hour
Answer: A
Explanation: An overstretched uterus is subject to hemorrhage. A large baby causes additional stretching of the
uterus. Answer 2 is not correct. Pitocin contracts the uterus and decreases hemorrhage. It is also standard
procedure following delivery. Answer 3 is not correct. Delivering after the due date itself does not increase
postpartum hemorrhage. However, the large baby does. Answer 4 is not correct. It is normal for the second stage
of labor to last an hour.
No comments:
Post a Comment