NR327 - Quiz 4 - Postpartum NCLEX-Style Questions (For Quiz 4) NR327 - Quiz 4 - Postpartum NCLEX-Style Questions (For Quiz 4)

NR327 - Quiz 4 - Postpartum NCLEX-Style Questions (For Quiz 4) - July 2019 Source Of Questions For This Quiz: Saunders Comprehensive Review - NCLEX-RN Exam Topics For This Quiz: Postpartum Physiologic Adaptations Postpartum Psychosocial Adaptations Postpartum Complications Assessment of the Normal Newborn Care of the Normal Newborn Postpartum NCLEX Material: Newborn NCLEX Material in Quizlets: 1. 2. Postpartum Physiological/Psychosocial Adaptations & Postpartum Complications NCLEX-Style Questions (For Quiz 4): 1. A nurse is performing a fundal assessment for a client who is 2 days postpartum and observes the perineal pad for lochia. she notes the pad to be saturated approximately 12 cm with lochia that is bright red and contains small clots. Which of the following findings should the nurse document? A. Moderate lochia rubra B. Excessive blood loss C. Light lochia rubra D. Scant lochia serosa Rationale: A. CORRECT: The client has moderate lochia rubra containing small clots, which is an expectedfinding for the second day postpartum. B. Excessive blood loss is saturation of a perineal pad in 15 min or less or pooling of blood underthe client's buttocks. C. Light lochia rubra is a perineal pad that is saturated less than 10 cm with lochia. D. Scant lochia serosa (less than 2.5 cm on perineal pad) is pinkish brown in color and serosanguineous in consistency. it occurs on day 4 to 12 following delivery." 2. 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 Rationale: A. A client who has a vaginal hematoma is expected to report excessive pain or vaginal pressure. B. Excessive spurting of bright red blood from the vagina indicates a possible cervical or perineal laceration. 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. D. Excessive blood loss consists of one pad saturated in 15 min or less or the pooling of blood under the buttocks, which is not affected by the client's postural changes." 3. 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." Rationale: A. A client is instructed to not get pregnant for 1 month following administration of varicella vaccine. B. CORRECT: A second varicella immunization is needed at 4 to 8 weeks following delivery by clients who had no history of immunity. C. Rho(d) immune globulin is administered to a Rh-Negative mother who has an rh-positive newborn. D. A client requires testing for immunity at 3 months following administration of rubella vaccine and rho(d) immune globulin." 4. 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 Rationale: B "a. Poor involution is the result of uterine atony and does not cause it. 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. c. hemorrhage is the result of uterine atony and does not cause it. d. infection does not cause uterine displacement or atony and would be characterized by foul-smelling vaginal discharge and elevated temperature." 5. 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 Rationale: A B "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. c. diaphoresis is the mechanism by which the excess fluid of pregnancy is removed