BANK EXAM 3 COMPLETE QUESTIONS & ACCURATE DETAILED
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during ambulation to the bathroom, a postpartum client experiences a gush of
dark red blood that soon stops. on assessment, a nurse finds the uterus to be firm,
midline, and at the level of the umbilicus. Which of the following findings should
the nurse interpret this data as being?
a. Evidence of a possible vaginal hematoma
B. an indication of a cervical or perineal laceration
c. a normal postural discharge of lochia
d. abnormally excessive lochia rubra flow
c. CORRECT: lochia typically trickles from the vaginal opening but flows more
steadily during uterine contractions. massaging the uterus or ambulation can
result in a gush of lochia with the expression of clots and dark blood that has
been pooled in the vagina, but it should soon decrease back to a trickle of
bright red lochia in the early puerperium.
a nurse is completing postpartum discharge teaching to a client who had no
immunity to varicella and was given varicella vaccine. Which of the following
statements by the client indicates understanding of the teaching?
a. "i will need to use contraception for 3 months before considering pregnancy."
B. "i need a second vaccination at my postpartum visit."
c."i was given the vaccine because my baby is o-positive."
d."i will be tested in 3 months to see if i have developed immunity."
B. CORRECT: a second varicella immunization is needed at 4 to 8 weeks
following delivery by clients who had no history of immunity.
,a nurse is assessing a postpartum client for fundal height, location, and
consistency. the fundus is noted to be displaced laterally to the right, and there is
uterine atony. the nurse should identify which of the following conditions as
the cause of the uterine atony?
a. Poor involution
B. urinary retention
c. hemorrhage
d. infection
B. CORRECT: urinary retention can result in a distention of the bladder. a distended
bladder can cause uterine atony and lateral displacement from the midline,
usually to the right.
a nurse is caring for a client who is 1 hr postpartum following a vaginal birth and
experiencing uncontrollable shaking. the nurse should understand that the
shaking is due to which of the following factors? (select all that apply.)
a. change in body fluids
B. metabolic effort of labor
c. diaphoresis
d. decrease in body temperature
E. decrease in prolactin levels
a. CORRECT: a shift in body fluids during the first 2 hr puerperium can cause a
postpartum chill.
B. CORRECT: the work of labor can cause a postpartum chill during the first 2
hr puerperium.
, a nurse is conducting a home visit for a client who is 1 week postpartum and
breastfeeding. the client reports breast engorgement. Which of the following
recommendations should the nurse make?
a. "apply cold compresses between feedings."
B. "take a warm shower right after feedings."
C."apply breast milk to the nipples and allow them to
air dry." d."use the various infant positions for
feedings."
a. CORRECT: Cold compresses applied to the breasts after the feedings can
help with breast engorgement.
a nurse is providing discharge instructions for a client. at 4 weeks postpartum,
the client should contact her provider for which of the following client
findings?
a. scant, nonodorous white vaginal discharge
B. uterine cramping during breastfeeding
C. sore nipple with cracks and fissures
d. decreased response with sexual activity
C. CORRECT: a sore nipple that has cracks and fissures is an indication of mastitis.
a nurse is providing discharge teaching for a nonlactating client. Which of the
following instructions should the nurse include in the teaching?
a. "Wear a supportive bra continuously for the first 72 hours."
B. "Pump your breast every 4 hours to relieve discomfort."
C."use breast shells throughout the day to decrease milk supply."
d."apply warm compresses until milk suppression occurs."
a. CORRECT: the nurse should instruct the client to wear a well‐fitting support
bra continuously for the first 72 hr.