Nclex-Rn Practice Questions-Maternal-Neonatal Care - Postpartum Care Part 2
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Question 1 |
On the first postpartum night, a client requests that her baby be sent back to the nursery so she can get some sleep. The client is most likely in which phase?
A | Depression phase |
B | Letting-go phase |
C | Taking-hold phase |
D | Taking-in phase |
Question 2 |
A postpartum client is receiving anticoagulant therapy for deep vein thrombophlebitis. What is the most important information for the nurse to include in discharge teaching?
A | Avoid iron replacement therapy. |
B | Wear a girdle and knee-high stockings whenever possible. |
C | Avoid over-the-counter salicylates. |
D | Be aware that shortness of breath is a common adverse effect of anticoagulants. |
Question 3 |
A nurse is performing an assessment on a postpartum client. The assessment reveals that the fundus is firm. The nurse interprets this as indicating:
A | a firm tumor at the top of the uterus. |
B | contraction of the uterus. |
C | continuing labor contractions. |
D | bladder distention. |
Question 4 |
When performing a comprehensive fundal check during a postpartum assessment, a nurse evaluates which fundal state?
A | Fundal consistency, location, and height |
B | Fundal consistency and height |
C | Fundal location and potential fundal distention |
D | Fundal location and height |
Question 5 |
The nurse is aware that which of the following is the most likely cause of uterine atony that may lead to postpartum hemorrhage?
A | Hypertension |
B | Cervical and vaginal tears |
C | Urine retention |
D | Endometritis |
Question 6 |
During the third postpartum day, which observation about a client should the nurse be most likely to make?
A | The client appears interested in learning more about neonatal care. |
B | The client talks a lot about her birth experience. |
C | The client sleeps whenever the neonate isn’t present. |
D | The client requests help in choosing a name for the neonate. |
Question 7 |
The nurse considers which of the following to be a normal physiological response in the early postpartum period?
A | Urinary urgency and dysuria |
B | Rapid diuresis |
C | Decrease in blood pressure |
D | Increased motility of the GI system |
Question 8 |
A client has delivered twins. What is the most important intervention for a nurse to implement?
A | Assess fundal tone and lochia flow. |
B | Apply a cold pack to the perineal area. |
C | Administer analgesics, as ordered. |
D | Encourage voiding by offering the bedpan. |
Question 9 |
Which activity by a client indicates that a nurse’s teaching about perineal care has been effective?
A | The client uses a spray bottle to cleanse the perineum after urination and bowel movements. |
B | The client wipes the perineum from back to front after urinating or a bowel movement. |
C | The client douches after urination or a bowel movement. |
D | The client changes perineal pads three times a day. |
Question 10 |
A nurse is reviewing the plan of care for a client with an episiotomy on the third postpartum day. It is most important for the plan to include which instruction?
A | Apply ice to the perineum. |
B | Encourage the use of sitz baths. |
C | Avoid tightening the pelvic muscles. |
D | Massage the perineal area. |
Question 11 |
Which client behavior indicates an understanding of the nurse’s teaching plan for breastfeeding?
A | The client washes her nipples with soap and water. |
B | The client lets her nipples air dry. |
C | The client lets the baby attach to the nipple only. |
D | The client pulls the baby off the nipple when feeding is done. |
Question 12 |
Which complication is associated with magnesium sulfate therapy?
A | Hypotension |
B | Postpartum depression |
C | Postpartum hemorrhage |
D | Uterine infection |
Question 13 |
A client with mastitis tells the nurse she is concerned about breastfeeding her neonate. What is the best response by the nurse?
A | Stop breastfeeding until completing the antibiotic. |
B | Supplement feeding with formula until the infection resolves. |
C | Do not use analgesics because they aren’t compatible with breastfeeding. |
D | Continue to breastfeed; mastitis won’t infect the infant. |
Question 14 |
The nurse is caring for a postpartum client who develops preeclampsia. Which medication should the nurse expect to administer?
A | Diazepam (Valium) |
B | Hydralazine |
C | Magnesium sulfate |
D | Nifedipine (Procardia) |
Question 15 |
A client who is breastfeeding reports pain, redness, and swelling in her right breast. What is the most important information for the nurse to give the client?
A | Wear a tight-fitting brassiere while breastfeeding. |
B | Breastfeeding should be stopped permanently. |
C | Continue antibiotic until pain, redness, and swelling subside. |
D | Apply moist heat compresses to the right breast. |
Question 16 |
A mother with diabetes tells the nurse she wants to breastfeed but is concerned about the effects of breastfeeding on her health. What is the best response by the nurse?
A | Mothers with diabetes who breastfeed have a hard time controlling their insulin needs. |
B | Mothers with diabetes shouldn’t breastfeed because of potential complications. |
C | Mothers with diabetes shouldn’t breastfeed; insulin requirements are doubled. |
D | Mothers with diabetes may breastfeed; insulin requirements may decrease from breastfeeding. |
Question 17 |
Which statement by a client shows an understanding of how to prevent breast engorgement while breastfeeding?
A | “I will apply moist heat to my breasts three times a day.” |
B | “I will breastfeed every 1 to 3 hours.” |
C | “I will use a breast pump to obtain milk for feedings.” |
D | “I will wear a tight bra continually.” |
Question 18 |
A primipara who is Rho(D) negative has just given birth to an Rh-positive baby. Which priority nursing intervention should be included in the plan of care?
A | Administer Rho(D) immune globulin to the neonate within 3 days. |
B | Administer Rho(D) immune globulin to the client within 3 days. |
C | Administer Rho(D) immune globulin to the client at her first postpartum visit in 6 weeks. |
D | Administer Rho(D) immune globulin to the neonate at the first well-baby visit. |
Question 19 |
The nurse is concerned that a client who experienced a perinatal loss 3 days ago may being exhibiting signs of dysfunctional grieving. It is important to assess the client for which sign?
A | Lack of appetite |
B | Denial of the death |
C | Blaming herself |
D | Frequent crying spells |
Question 20 |
A client needs to void 3 hours after a vaginal delivery. Which risk factor necessitates assisting her out of bed?
A | Chest pain |
B | Breast engorgement |
C | Orthostatic hypotension |
D | Separation of episiotomy incision |
Question 21 |
Prior to administration of the rubella vaccine, what is the most important information for the nurse to teach the client?
A | The vaccine is safe in clients with egg allergies. |
B | Breastfeeding isn’t compatible with the vaccine. |
C | Transient arthralgia and rash are uncommon adverse effects. |
D | The client should avoid getting pregnant for 3 months after the vaccination because the vaccine has teratogenic effects. |
Question 22 |
A 6-week postpartum client is being assessed by the nurse at the obstetrician’s office. The nurse notes that the uterus is enlarged and soft and that the client is experiencing vaginal bleeding. The nurse suspects the client has which condition?
A | Cervical laceration |
B | Clotting deficiency |
C | Perineal laceration |
D | Uterine subinvolution |
Question 23 |
The nurse is assessing a 6-week postpartum client in the obstetrician’s office. In the exam room, the nurse asks the client how she’s feeling. The client bursts into tears and reports she can barely get out of bed to dress, is crying most of the time, and feels like a failure. The nurse suspects the client is experiencing which condition?
A | Postpartum blues |
B | Postpartum depression |
C | Postpartum neurosis |
D | Postpartum psychosis |
Question 24 |
An Rh-positive client has just delivered a 6 lb, 10 oz neonate vaginally after 17 hours of labor. What factor may place this client at risk?
A | Length of labor |
B | Maternal Rh status |
C | Method of delivery |
D | Size of the baby |
Question 25 |
Four clients each gave birth 12 hours ago. The nurse determines that which client would most likely suffer complications after birth?
A | Gravida 2 Para 2002, cesarean birth, incisional site intact, hemoglobin level 9.8 g/dl |
B | Gravida 2 Para 1011, cesarean birth, incisional site intact, pulse 84 beats/minute |
C | Gravida 1 Para 1001, vaginal delivery, midline episiotomy, temperature 99.8° F (37.7° C) |
D | Gravida 1 Para 1001, vaginal delivery, ruptured membranes 10 hours before delivery |
Question 26 |
A nurse is assessing a multiparous client on her first postpartum day. Which assessment finding indicates that the client is at risk for hemorrhage?
A | Hemoglobin level of 12 g/dl |
B | Uterine atony |
C | Thrombophlebitis |
D | Moderate amount of lochia rubra |
Question 27 |
A nurse is assessing the fundus of a client who is 12 hours postpartum and finds that the fundus is boggy. Which action should the nurse take first?
A | Prepare the client for surgery. |
B | Administer blood replacement products. |
C | Massage the fundus. |
D | Administer methylergonovine (Methergine), as ordered. |
Question 28 |
Which percentage of postpartum clients experiences “postpartum blues”?
A | 20% to 25% |
B | 50% to 80% |
C | 30% to 45% |
D | 100% |
Question 29 |
Which assessment finding of a client 22 hours after a cesarean delivery requires immediate action by the nurse?
A | Heart rate of 132 beats/minute and blood pressure of 84/60 mm Hg |
B | Oral temperature of 100.2° F |
C | A gush of blood from the vagina when the client stands up |
D | Complaints of abdominal pain and cramping |
Question 30 |
A nurse is caring for a breastfeeding client who delivered by cesarean section. What is the most important information for the nurse to teach the client?
A | Delay breastfeeding until 24 hours after delivery. |
B | Breastfeed frequently during the day and every 4 to 6 hours at night. |
C | Use the cradle hold position to avoid incisional discomfort. |
D | Use the football hold position to avoid incisional discomfort. |
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