N230 - Olol - Nclex Questions For Test 2

Front 1

What suggestion should the nurse provide to the client who complains of severe afterpains?

Back 1

Assume a prone position at intervals.

Afterpains are severe in multiparous women. The prone position puts pressure on the uterus, which stimulates uterine contraction

Front 2

A nurse is assessing the lochia in a 24-hour-postpartum client, and expresses blood clots with fundal massage. The client's fundus is firm but elevated and deviated to the right. What would be the most appropriate nursing action?

Back 2

Assess voiding pattern.

Monitor urine output to assess if the bladder is emptying regularly, as a distended bladder may prevent the uterus from contracting, leading to a collection of blood and the formation of blood clots.

Front 3

A nurse is preparing a postpartum client for discharge. The client's medical record reveals the following data: headaches relieved by aspirin, drinks one glass of wine per day, walks 2 miles each day, and smokes a half a pack of cigarettes per day. While instructing the client about the medication methylergonovine maleate (Methergine), the nurse cautions the client to avoid:

Back 3

Smoking.

The nurse should instruct the client to avoid smoking. Because Methergine has a vasoconstrictive effect on all blood vessels, and cigarette smoking can also lead to constricted blood vessels due to the nicotine, this combination may lead to hypertension.

Front 4

A nurse is caring for a 6-hour-postpartum client who is experiencing perineal discomfort. Which intervention is most appropriate for the nurse to implement?

Back 4

Application of an ice pack to the perineum

Ice packs applied to the perineum for the first 24 hours help reduce edema and promote comfort. Warm compresses do not help reduce edema. Methergine is used to stimulate the uterus to contract and is not indicated for relief of perineal discomfort. There is no indication to call the physician/CNM because perineal discomfort is common in postpartum women

Front 5

A nurse is assigned to care for four postpartum clients. Which client would be least likely to request relief for afterpains?

Back 5

Gravida 1, para 1 with a 16-hour labor.

Afterpains are intermittent uterine contractions, and since a primipara's uterus is able to maintain a steady contracted state, afterpains are usually not severe. Afterpains may result from hydramnios with an overdistended uterus, multiparity caused by an overdistended uterus, or breastfeeding, which stimulates the release of oxytocin during suckling. In these situations, the uterus works harder to maintain a contracted state, causing afterpains.

Front 6

A nurse is administering medication to several postpartum clients. What order should the nurse question?

Back 6

Rubella vaccine, 1 vial SQ daily

Rubella vaccine is given to women to stimulate active immunity against the rubella virus and women who have a rubella titer of less than 1:10. Rubella vaccine is given once in the postpartum period, not daily

Front 7

The nurse knows that the client understands the discharge instructions after receiving a rubella vaccination when she overhears her client tell her husband:

Back 7

Avoiding pregnancy for 3 months following rubella vaccination is important to avoid causing birth defects in the forming fetus.

Front 8

nurse is caring for a couple in the birthing center. Which parent-infant behaviors should the nurse investigate further?

Back 8

The parents complete activities silently without looking at the baby.

Good attachment behaviors include seeking eye contact with the baby and talking to the baby during caretaking activities; the nurse should investigate the behaviors when these are not observed.

Front 9

A 24-hour-postpartum client who had a cesarean birth with general anesthesia complains of abdominal discomfort and gas pains. What is the most appropriate nursing intervention?

Back 9

Position client on left side.

Positioning the client on the left side allows for the gas to rise from the descending colon to the sigmoid colon so it may be expelled. Analgesic medication does not relieve gas, but antiflatulents such as Mylicon may help relieve gas.

Front 10

What parameters does the nurse use to judge how well involution is progressing in a postpartum client? Select all that apply

Back 10

Fundal consistency

Fundal location

Amount and character of lochia

The nurse can make the determination that involution is progressing in a normal manner by assessing these parameters: (1) that the fundus is descending into the pelvis at a normal rate and that it is contracted; a firm, midline fundus indicates normal involution; (2) the amount and character of lochia; excessive or foul-smelling lochia indicates problems.

Front 11

Which woman who has unprotected sexual relations is most at risk for an unintentional pregnancy during the postpartum period?

Back 11

A non-nursing mother who is 8 weeks postpartum

In non-nursing mothers, menstrual periods generally return in 6-10 weeks. They may ovulate prior to the first period. Nursing mothers usually have their first menstrual period delayed for at least 3 months, and they are prone to anovulatory cycles, putting them at lower risk for pregnancy

Front 12

Which woman is most at risk for bladder distention after a normal vaginal delivery?

Back 12

A woman who had epidural anesthesia

Every woman is at risk following delivery, and the nurse must assess voiding patterns after delivery. However, the biggest risk factor is anesthesia, which affects the sensory nerves, because the woman is unaware of the need to empty her bladder

Front 13

What is the nurse's chief concern when a mother who delivered 2 hours ago has a blood pressure change from 112/70 to 142/94?

Back 13

Developing pre-eclampsia

This is a significant increase in the blood pressure, and the most dangerous complication at this point is the occurrence of pre-eclampsia. In a postpartum woman, diuresis should control the fluid volume and hypertension should not develop.

Front 14

The nurse is assessing a postpartum client who gave birth 10 hours ago. What assessment finding would need further investigation by the nurse?

Back 14

Fundus is deviated to the right.

A fundus that is deviated to the right is not a normal finding, and may be due to a full bladder. A fundus that is at the level of the umbilicus or 2-3 cm below, firm, and midline is normal.

Front 15

The nurse assesses an 8-hour-postpartum client. Findings include lochia rubra, with a firm fundus at the level of the umbilicus. What nursing action is indicated?

Back 15

Document findings and continue to monitor.

The client's findings are within normal limits. Document findings and continue to monitor. Early postpartum hemorrhage presents with a boggy, nonfirm fundus

Front 16

The nurse is researching the relationship between estrogen and lactation. The nurse discovers that the lactating client is more susceptible to:

Back 16

Dyspareunia.

Lactation puts breastfeeding women in a hypoestrogenic state due to ovarian suppression, which could lead to dyspareunia (painful intercourse).

Front 17

The nurse is caring for four high-risk postpartum clients. Which predisposing conditions place a client at risk for developing hemorrhage? Select all that apply.

Back 17

Precipitous labor

Twin gestation

(Increased blood pressure associated with pregnancy-induced hypertension places clients at an increased risk for pulmonary edema. A client with diabetes is at risk for poor healing, hypoglycemia, and hyperglycemia. A client with premature rupture of membranes is at increased risk for maternal infection.) Precipitous labor and twin gestation put the client at risk for hemorrhage

Front 18

A nurse is caring for four postpartum clients. Which have an increased risk of thrombophlebitis? Select all that apply.

Back 18

The client with a cesarean birth

The client with pre-eclampsia

Pre-eclampsia and cesarean section prolong the need for bed rest and increase the risk of clotting leading to increased risk of thrombophlegitis. Increased temperature and WBC have nothing to do with increased risk of clotting.

Front 19

What laboratory values should the nurse report to the credentialed practitioner immediately when caring for a patient who had a C-section yesterday? Select all that apply.

Back 19

Hematocrit of 29%

Sodium of 129

A leukocytosis is normal after delivery. The hematocrit is too low. A drop of 2 points equals about 500 ml of blood loss. The platelet count is only slightly decreased, which normally occurs following delivery. The BUN is normal, but the low sodium could predispose to seizures.

Front 20

A 24-year-old primipara is holding her new infant. Which behaviors indicate normal mother-infant bonding 24 hours after delivery? Select all that apply.

Back 20

Fingertip exploration

Use of en face position

Reluctance to change diapers

Talking in a high-pitched voice

Fingertip exploration and the en face position are usual behaviors shown by new mothers. Mothers often will use a high-pitched voice when interacting with their newborns and frequently will verbalize concerns about the infant's appearance. Some first-time mothers are hesitant to change a diaper because they lack confidence in their abilities to do this

Front 21

A nurse is assessing a client 2 hours postpartum. Her blood pressure is 98/60, pulse is 90, and she has saturated two pads in the last hour. What should be the immediate nursing action?

Back 21

Massage fundus until firm.

The initial action is to assist the fundus to remain contracted, which will decrease bleeding. The fundus is checked frequently for firmness, and if it is boggy, the fundus is massaged until firm

Front 22

A nurse is assessing four postpartum clients with vaginal births. Which are at risk for uterine atony? Select all that apply.

Back 22

The client who received magnesium sulfate

The client who had an oxytocin induction

The client who had a precipitous labor

Oxytocin inductions and magnesium sulfate may cause uterine atony after delivery. Rapid labor indicates the uterus may have been contracting abnormally. A cerclage is performed for an incompetent cervix, which is not a risk factor for uterine atony

Front 23

A nurse is caring for four postpartum clients who each have an order for Methergine (methylergonovine maleate). Based on the data collected during the nurse's initial shift assessment, which client would not receive the medication?

Back 23

The client with a blood pressure of 156/94

Hypertension is a side effect of this medication; therefore, Methergine is contraindicated for women with high blood pressure.

Front 24

A nurse has assessed a 4 cm vaginal hematoma on a client who is 6 hours postpartum. In planning this client's care, what initial nursing intervention would be most appropriate?

Back 24

Apply ice packs every 4 hours for 24 hours

Application of ice packs helps reduce pain and swelling, and is the most appropriate initial action for a vaginal hematoma. Analgesic medication may be appropriate, but not as the initial action. Hot packs are used to assist in the treatment of thrombophlebitis. An indwelling catheter may be helpful if a vaginal pack is in place.

Front 25

A client who is 4 weeks postpartum has irregular bleeding of lochia rubra with her fundus measured at 1 cm below the umbilicus. Based on these findings, what medication would the nurse anticipate the physician or midwife ordering for this client?

Back 25

Methergine (methylergonovine maleate)

Methergine is the treatment of choice for subinvolution. Percodan and Motrin are ordered for pain management. Hemabate is used for immediate postpartum hemorrhage related to uterine atony.

Front 26

A nurse is caring for a client who is 4 hours postpartum with postpartum hemorrhage. Which nursing diagnosis has the highest priority?

Back 26

Fluid Volume Deficit, related to blood loss secondary to uterine atony

Fluid volume deficit takes priority because blood loss can cause more severe and more life-threatening problems.

Front 27

A nurse is reviewing the lab reports of a 24-hour-postpartum client. The admission hematocrit was 41%, and the current hematocrit is 30%. What should be the initial nursing action in response to this report?

Back 27

Report the lab values to the physician or midwife.

Some clinicians think postpartal hemorrhage can be objectively and reliably defined as either a decrease in the hematocrit of 10 points between the time of admission and the time postbirth or the need for fluid replacement following childbirth. This is an abnormal finding and warrants further investigation by the physician or midwife. The lab reading should be accurate, so it would be inappropriate and unnecessary to have the lab redrawn. Increasing the infusion rate may be appropriate if there are symptoms of hypovolemia, but it is not the initial action. Administering 2 units of blood would not be the initial action, but may be ordered later.

Front 28

The nurse caring for a postpartum client with an episiotomy notes that the client complains of rectal pressure and increasing perineal pain. What are the priority responses for the nurse to make at this time? Select all that apply

Back 28

Assess for a vaginal hematoma.

Assess for incomplete bladder emptying.

Once the effects of anesthesia have subsided, vaginal and vulvar hematomas generally cause perineal pain. The pain is often intense, out of proportion, or excessive, and usually from the woman's stitches. If the hematoma is in the posterior vaginal area, rectal pressure may also be a presenting complaint. Hematomas in the upper vagina may cause difficulty voiding because of pressure against the urinary meatus or urethra. Rather than automatically attributing complaints of perineal pain to an episiotomy, examine the perineal area for signs of hematomas: ecchymosis; edema; tenseness of tissue overlying the hematomas; fluctuant, bulging mass at the introitus; and extreme tenderness to palpation. The nurse may want to assess bowel habits, but the determination of hemorrhage takes priority over bowel movements. Assessment should be completed of the cause of pain before intervening by giving pain medication, especially since hemorrhage is a factor.

Front 29

A nurse is caring for a 48-hour-postpartum client who complains of urinary frequency and dysuria. Her temperature is 100.2ºF, pulse 72, respirations 18, and blood pressure 108/72. The nurse should anticipate an order to:

Back 29

Obtain a urine culture.

Frequency and dysuria warrant further investigation, and clean-catch urine specimen could identify the causative organism if an infection were present. It is inappropriate to administer antibiotics before confirming presence and causative agent of infection. Inserting a catheter would be inappropriate because the procedure may increase the chance of introducing an infection through the catheter into the bladder. Administering an anti-inflammatory medication at this time is inappropriate, although an antispasmodic medication may be helpful.

Front 30

Which women are at increased risk of developing endometritis after giving birth? Select all that apply.

Back 30

A woman who had a cesarean delivery

A woman who had an intrauterine pressure device used during labor

A woman who had a forceps-assisted vaginal birth

Parity, being either a first-time mother or the mother of many children, is not a risk factor for uterine infection. Use of any instrumentation, such as in a cesarean birth, a forceps-assisted delivery, or the use of an intrauterine pressure catheter, greatly increases the chances of infection.

Front 31

client born at 27 weeks gestation develops grunting, nasal flaring, and decreased oxygenation. Based on the client's gestational age, there is more than likely a deficiency in surfactant. The parent questions the nurse about the cause. The nurse tells the parent that surfactant is critical for:

Back 31

Alveolar stability.

Surfactant prevents the alveoli from completely collapsing with each expiration, thus promoting lung expansion. Other options are important for inspiratory and expiratory cycles but are not pertinent in the discussion of functioning alveoli of the lung.

Front 32

A priority intervention that the nurse must do immediately after delivery is suctioning out the baby's mouth and nares. Why?

Back 32

Suctioning removes 80-110 ml of fluid that remains in the respiratory passages, permitting adequate movement of air.

It is stated that 80-110 ml of fluid remains in the respiratory passages that must be removed to permit adequate movement of air. Surfactant decreases surface tension and prevents alveolar collapse. Although the initial chest recoil assists in clearing fluid from the airways and permits further inspiration, most clinicians believe mucus and fluid should be suctioned from the newborn's mouth, nose, and throat. Suctioning does not increase the pulmonary vascular resistance

Front 33

Which of the following factors occurring antenatally or during labor and birth can interfere with adequate newborn lung expansion? Select all that apply.

Back 33

Meconium aspiration

Premature birth

Cesarean birth

Respiratory depression

Complications that occur before or during labor and birth can interfere with adequate lung expansion and cause failure to decrease pulmonary vascular resistance, resulting in decreased pulmonary blood flow. These complications include inadequate compression of the chest wall in a very small newborn, the absence of chest wall compression in a newborn born by cesarean birth, respiratory depression due to maternal anesthesia, or aspiration of amniotic fluid or meconium

Front 34

A routine hematocrit level is drawn on a newborn immediately after delivery and is found to be 68%. What may have contributed to this abnormally high hematocrit level?

Back 34

Delayed cord clamping

Blood volume increases by approximately 50% with delayed cord clamping; this increase is reflected by a rise in hematocrit level to about 65%. Congenital heart defects, leukocytosis, and hypovolemia are not related at all to high hematocrit levels.

Front 35

To create a neutral thermal environment for a newborn, immediately after delivery, the nurse must consider which of the following?

Back 35

Minimal stimulation, and place under the radiant warmer bed.

A newborn should be suctioned only when indicated, and this intervention is not related to temperature regulation. Minimal stimulation is suggested to conserve heat and energy (perform grouped cares). The newborn should be placed in a flexed position to decrease exposed surface tension, decreasing amount of heat lost.

Front 36

Which of the following interventions results in convection heat loss in the newborn?

Back 36

Removal from an incubator for procedures

Convection is defined as loss of heat from the warm body surface to the cooler air currents. The other options are examples of radiation, evaporation, and conduction

Front 37

Upon physical examination, the nurse notes the liver of a newborn is palpable 2-3 cm below the right costal margin. The nurse recognizes this finding and should perform the following?

Back 37

Recognize this as a normal physical finding.

In the newborn, the liver is palpable 2-3 cm below the right costal margin. It is relatively large and occupies 40% of the abdominal cavity. This is a completely normal finding.

Front 38

A newborn has developed physiologic jaundice as verified by high bilirubin levels found in the blood. What appropriate interventions would a nurse expect to perform in this scenario? Select all that apply.

Back 38

Increase IV fluids.

Place newborn under bili-lights, protecting eyes and genitalia.

The combination of increasing IV fluids and placing under bili-lights is the best intervention to perform to decrease a bilirubin level. Nursing care is directed at keeping the newborn well hydrated and promoting elimination. Check for metabolic acidosis rather than alkalosis; making newborn NPO will increase bilirubin levels.

Front 39

Which of the following physical assessment findings indicates a need for further evaluation?

Back 39

Absence of the rooting reflex

Absence or delayed disappearance of reflexes will always be a concern and a reason to refer for developmental screening. Flexion is expected. Hypotonia would be a definite need for a referral. Brisk knee jerk and plantar flexion should be found upon exam of the newborn.

Front 40

A breastfeeding client is attempting to soothe a 2-day-old crying newborn. The client finds a pacifier and places it in the newborn's mouth. What is the nurse's best response?

Back 40

Pacifiers are discouraged until breast feeding is well established.

Pacifiers should be offered to breastfed infants only after breastfeeding is well established. If the pacifier is offered too soon, a phenomenon called nipple confusion may occur in the breastfed infant. Never coat the pacifier with sugary substances. Pacifiers are encouraged once breastfeeding is well established.