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Terms in this set (31)A nurse in postpartum unit is caring for a client who 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? b, A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. When the nurse locates the funds, she notes that the uterus feels soft and boggy. Which nursing intervention would be appropriate? b. A nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breastfeeding her newborn. Which of the following, if stated by the client, would. Indicate a need for further instructions? d. client should avoid soap on nipples as it could cause drying and additional cracking. A nurse is assessing a client in the fourth stage of labor and notes that the funds is firm, but that bleeding is excessive. Which of the following would be the initial nursing action? b. the cause may be laceration of the cervix or birth canal. Massaging the funds would not assist in controlling the bleeding. Trendelenberg position should be avoided because it may interfere with cardiac and respiratory function. Initial action would be to notify the physcian A nurse is preparing a list of self care instructions for a postpartum client who was diagnosed with mastitis. Which of the following instructions would be included on the list? A. b, c, d A nurse in a newborn nursery is monitoring a preterm newborn for respiratory
distress syndrome. Which assessment sings noted in the newborn would alert the nurse to the possibility of this syndrome? A. A postpartum nurse is providing instructions to the mother of a newborn with hyperbillirubinemia who is being breast fed. The nurse provides
which appropriate instruction to the mother? b. A nurse assessing a newborn who was born to a mother who is addicted to drugs. Which assessment findings would the nurse expect to note during the assessment of
this newborn? c. a newborn of a woman using drugs is irritable. The infant is overloaded easily by sensory stimulation. The infant may cry incessantly and be difficult to console. The infant would hyperextend and posture rather than cuddle when being held A nurse is planning care for a newborn of a diabetic mother. A priority
nursing diagnosis for this infant is: b A nurse is preparing to care for a newborn receiving phototherapy. Which interventions are appropriate? d,e,f Methergine is prescribed to a client with postpartum hemorrhage. Before administering the medication, a nurse contacts the health care provider who prescribed the medication is which condition is
documented in the clients medical history? d. Methergine is prescribed for a woman to treat postpartum hemorrhage. Before administration the priority nursing assessment is to check the: b. contraindicated in patients with hypertension because this medication may cause hypertension A nurse is preparing to administer survanta to a premature infant who has respiratory distress syndrome. The nurse plans to administer this medication by which of the following routes? b. Rho (D)
immune globulin (RhoGam) is prescribed for a client after delivery and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose if the woman states that it will protect her next baby from which of the following? d On assessment, a newborn is exhibiting cyanosis, tachypnea, nasal flaring, and grunting. Respiratory distress syndrome is diagnosed, and the physician prescribes surfactant replacement therapy. The nurse prepares to administer this therapy by: d. A 4 day old newborn is receiving phototherapy at home for a bilirubin level of 14. The nurse should plan to include which of the following in the teaching plan of care? b. A new mother is seen in a health care clinic 2 weeks after giving birth. The mother is complaining that she feels as though she has the flu and complain of fatigue and aching muscle. 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 appropriate response is which of the following? b A 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. The nurse prepares immediately to : d A nurse in monitoring a postpartum client in the fourth stage of labor. Which of the following findings, if noted by the nurse, would indicate a complication related to a laceration of the birth canal? c A nurse is providing instructions to a client who has been diagnosed with mastitis. Which of the following statement, if made by the client, indicated a need for further instructions? b. in most cases mother can continue to breast feed, if the affected breast is too sore, the mother can pump the breast gently. Regular emptying of the breast is important to prevent abscess formation Nurse
in a newborn nursery is performing admission vital signs on a newborn infant. The nurse notes that the respiratory rate is 50 breaths per minute. Which of the following is the appropriate nursing action? b. for rate is 30-60 A nurse is monitoring a
postpartum client who is at risk of developing endometritis. Which of the following, if noted during the first 24 hours after delivery, would support a diagnosis of postpartum endometritis? c A nursing caring for a postpartum client with a diagnosis
of endometritis notes that the client has little interest in caring for her newborn. Which of the following nursing interventions would be appropriate to facilitate participation in newborn care? a A nurse is assessing a client in
the postpartum period and suspects the presence of uterine atony. The initial nursing action should be to: A. when uterine atony occurs, the initial nursing action would be to massage the uterus until firm. If this does not assist in controlling the blood loss, then the nurse would contact the physician. Additionally, once bleeding is under control, the nurse would monitor the vital signs and estimate blood loss 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 prepares to implement which of the following interventions? A,c, e The nurse is developing a plan of care for a preterm newborn infant. The nurse develops measures to provide skin care, knowing that preterm newborn infants skin appears: a A nurse is caring for a post term, small for gestational age newborn infant immediately after admission to the nursery. The priority nursing action would be to monitor which of the following? c A nurse is performing an initial assessment on a large for gestational age newborn infant. Which physical assessment technique would the nurse perform to assess for evidence of birth trauma? a A nurse in the newborn nursery is assessing a neonate who was born of a mother addicted to cocaine. Which of the following would the nurse expect to note in the neonate? a A nurse is instructing
a postpartum client with endometritis about preventing the spread of infection to the newborn infant. The nurse would tell the client that: a On assessment of a client
who is 30 minutes in to the fourth stage of labor, the nurse finds the clients perineal pad saturated in blood and blood soaked into the bed linen under the clients buttocks. The nurses initial action is which of the following? c Students also viewedIntrapartum NCLEX questions14 terms anselmoab POSTPARTUM41 terms riva_reina_v_ Intrapartum82 terms meg_m21Plus Saunders NCLEX Postpartum Questions88 terms KTBM Sets found in the same folderIntrapartum82 terms meg_m21Plus POSTPARTUM COMPLICATIONS11 terms Mikejohnson23 STD's45 terms Qwerty98765 Newborn Saunders NCLEX questions72 terms karyn_johnson9 Other sets by this creatorHIV/AIDS31 terms Qwerty98765 Hepatitis15 terms Qwerty98765 Chapter 29& 30 High Risk Newborn12 terms Qwerty98765 Chapt 26 Pregnant women with Comp10 terms Qwerty98765 Verified questions
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What is the appropriate way to assess the fundus of the postpartum patient?What is the appropriate way to assess the fundus of the postpartum patient? The proper way to assess the fundus of a mother who has just given birth is by placing one hand on the lower uterine segment while the other hand locates the fundus of the uterus.
What nursing interventions should the nurse perform based on her findings when assessing fundus?(5) Nursing interventions. (a) Palpate the fundus frequently to determine continued muscle tone. (b) Massage the fundus, if boggy, until firm (do not over massage, this fatigues the muscle). (c) Monitor patient's vital signs every 15 minutes until stable.
What assessments should the nurse to perform on the postpartum patient?The nurse can remember the key points of a postpartum assessment by learning the acronym BUBBLE-LE, which stands for breasts, uterus, bladder, bowels, episiotomy, lower extremities, and emotions. BUBBLE-LE is an acronym to remember the key points for postpartum nursing assessment.
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Which nursing action is needed when preparing for assessment of the fundus of a postpartum client quizlet?
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