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When admitting a client to the labor and delivery unit, which is the priority assessment?
Gravida and para status
Time of last meal
Presence of a labor partner
Contraction frequency and duration - ANSWERS-Contraction frequency and duration
The nurse is caring for a client in labor who is receiving oxytocin. Which assessment
finding requires immediate action?
Urine output 75 mL in 2 hours
Six contractions in 10 minutes
Contraction duration 50-60 seconds
Fetal heart rate 125 bpm with moderate variability - ANSWERS-Six contractions in 10
minutes
In what situation might a pregnant woman remain in the same hospital room from
labor/induction admission through postpartum discharge?
When the woman has a cesarean delivery planned
In a larger hospital with larger rooms available
When the pregnancy is high risk
,In a maternity unit set up with labor, delivery, recovery, and postpartum (LDRP) rooms -
ANSWERS-In a maternity unit set up with labor, delivery, recovery, and postpartum
(LDRP) rooms
How long does it typically take for a woman who has delivered a baby to return to a pre-
pregnant physical state?
2 weeks
6 months
1 year
6 weeks - ANSWERS-6 weeks
Which findings may indicate a deep vein thrombosis (DVT) in a lower extremity in a
postpartum woman? Select all that apply.
Bilateral redness
Pedal edema
Weak pedal pulse in the affected extremity
Localized warmth
Tenderness - ANSWERS-Weak pedal pulse in the affected extremity
Localized warmth
Tenderness
The nurse should include which interventions to promote involution of the uterus into
postpartum care of the mother? Select all that apply.
Breastfeeding
Administration of oxytocin
Uterine massage
Herbal tea
Ambulation - ANSWERS-Breastfeeding
Administration of oxytocin
Uterine massage
,The nurse completing the BUBBLE-HEER postpartum assessment determines that the
woman's patellar deep tendon reflexes are 1+. What does this finding indicate?
May be a sign of preeclampsia
The reflex assessment was inaccurate
These are normal findings
The reflexes are hyperactive - ANSWERS-These are normal findings
Which actions should the nurse take to help a first-time mother bond with her infant?
Select all that apply.
Encourage the mother to hold the newborn from birth
Postpone all nursing actions that require the newborn to be removed from the mother's
arms
Encourage the mother to allow you to take the newborn to the nursery every 2 hours to
allow her to rest
Compliment her on her child
Assess for signs which indicate that normal attachment is taking place - ANSWERS-
Encourage the mother to hold the newborn from birth
Compliment her on her child
Assess for signs which indicate that normal attachment is taking place
What common postpartum bodily alterations might cause a woman to experience
abnormal vital signs? Select all that apply.
Complications from epidural or spinal anesthesia
Presence of pain
Presence of infection after 24 hours
Fluctuating hormone levels
Hypovolemia due to blood loss - ANSWERS-Complications from epidural or spinal
anesthesia
Presence of pain
Presence of infection after 24 hours
, Hypovolemia due to blood loss
The nurse is assisting a new mother to ambulate for the first time after delivery. Which
questions should the nurse address to determine if the woman is ready to walk? Select
all that apply.
Is her blood pressure elevated?
What was the estimated blood loss at delivery?
Is her blood pressure low?
Following an epidural, has the feeling returned to her lower extremities? - ANSWERS-
What was the estimated blood loss at delivery?
Is her blood pressure low?
Following an epidural, has the feeling returned to her lower extremities?
The nurse is assessing a woman who gave birth vaginally 12 hours ago. The woman
had a second-degree perineal laceration that was repaired and she had an epidural for
anesthesia. Which actions by the nurse would be appropriate? Select all that apply.
Ask about her pain level
Explain that vital signs will be assessed every 12 hours
Advise that she is no longer at risk for perineal infection
Assess the perineum by asking if it feels less swollen
Palpate the tone and level of the uterus in relation to the umbilicus
Assess the characteristics of the lochia on the peri-pad - ANSWERS-Ask about her pain
level
Palpate the tone and level of the uterus in relation to the umbilicus
Assess the characteristics of the lochia on the peri-pad
Which of the following does the nurse need to consider when providing postpartum
teaching to the mother?
If the woman has already had a baby, she will not require as much postpartum teaching.
The mother will be well rested and focused on the information after she's been able to
nap.