Question 1 See full question
A nurse encourages a postpartum client to discuss the childbirth experience. Which
client outcome is most appropriate for this client?
You Selected:
"The client demonstrates the ability to integrate the childbirth experience and
progress to the task of maternal role attainment."
Correct response:
"The client demonstrates the ability to integrate the childbirth experience and
progress to the task of maternal role attainment."
Explanation:
Discussing the childbirth experience helps the client acknowledge and understand what
happened during this event. The nurse should give the client a chance to ask questions
about the event and seek clarification, if needed. After the client discusses the event,
she may be able to shift the focus away from herself and begin the tasks that will help
her assume the maternal role. The nurse must determine the client's understanding of
her physical needs and those of her neonate after teaching and demonstrating care
techniques; discussing the childbirth experience won't help her to meet these needs.
Remediation:
Discharge Planning, Neonatal
Question 2 See full question
A nurse is teaching a client about hormonal contraceptive therapy. If a client misses
three or more pills in a row, the nurse should instruct the client to:
You Selected:
discard the pack, use an alternative contraceptive method until her period
begins, and start a new pack on the regular schedule.
Correct response:
discard the pack, use an alternative contraceptive method until her period
begins, and start a new pack on the regular schedule.
Question 3 See full question
A client is 9 days postpartum and breast-feeding her neonate. The client experiences
pain, redness, and swelling of her left breast and is diagnosed with mastitis. The nurse
teaching the client how to care for her infected breast should include which information?
You Selected:
, Use a warm moist compress over the painful area.
Correct response:
Use a warm moist compress over the painful area.
Explanation:
Warm, moist compresses will reduce inflammation and edema of the infected breast
tissue. The woman with mastitis should wear a proper fitting bra with good support.
Breast-feeding does not have to be interrupted. The client will also need to pump the
breast to keep the breast empty of milk and to ensure an adequate milk supply.
Adequate emptying of the affected breast helps prevent more bacteria from collecting in
the breast and may shorten the duration of the infection. Antibiotics must be taken for
the full course of therapy and not stopped when symptoms subside.
Remediation:
Question 4 See full question
Which measure included in the care plan for a client in the fourth stage of labor requires
revision?
You Selected:
Obtain an order for catheterization to protect the bladder from trauma.
Correct response:
Obtain an order for catheterization to protect the bladder from trauma.
Explanation:
Catheterization isn't routinely done to protect the bladder from trauma. It's done,
however, for a postpartum complication of urinary retention. The other options are
appropriate measures to include in the care plan during the fourth stage of labor.
Remediation:
Question 5 See full question
A 15-year-old client gives birth to a healthy neonate. The neonate's adolescent father
arrives on the unit demanding to see his baby. Both sets of grandparents are also
present and asking to see their grandchild. The newly hired nurse assigned to the
nursery should take which action?
You Selected:
Discuss the unit's policy with the charge nurse.
Correct response:
, Discuss the unit's policy with the charge nurse.
Explanation:
Remediation:
Question 6 See full question
After the first breastfeeding, the client asks the nurse, “How often should I try to
breastfeed?” What frequency should the nurse recommend?
You Selected:
every 2 to 3 hours for the first 48 hours
Correct response:
every 2 to 3 hours for the first 48 hours
Explanation:
Soon after giving birth, the client should breastfeed every 2 to 3 hours until her milk
supply is established.
Remediation:
Question 7 See full question
While assessing a primipara during the immediate postpartum period, the nurse plans to
use both hands to assess the client's fundus to:
You Selected:
promote uterine involution.
Correct response:
prevent uterine inversion.
Explanation:
Using both hands to assess the fundus is useful for the prevention of uterine inversion.
With one hand, the nurse should support the position of the lower uterus and cervix,
while palpating the fundus with the other hand.
Using both hands does not hasten or promote uterine involution, which lasts about 6
weeks from the time of childbirth.
Using both hands to assess the fundus will not hasten the puerperium period.
, Determining the size of the fundus may be important if the client is experiencing
excessive lochia because an enlarged fundus may be an indicator of retained blood
clots or placenta fragments. The nurse, though, does not need to use both hands to
determine this.
Remediation:
Question 8 See full question
The nurse from the nursery is bringing a newborn to a mother’s room. The nurse took
care of the mother yesterday and knows the mother and baby well. The nurse should
implement which action to ensure the safest transition of the infant to the mother?
You Selected:
Complete the hospital identification procedure with mother and infant.
Correct response:
Complete the hospital identification procedure with mother and infant.
Explanation:
Remediation:
Question 9 See full question
Which client statement indicates effective teaching about burping a breastfed neonate?
You Selected:
“When I switch to the other breast, I’ll burp the baby.”
Correct response:
“When I switch to the other breast, I’ll burp the baby.”
Explanation:
Remediation:
Question 10 See full question
During a home visit on the fourth postpartum day, a primiparous client tells the nurse
that she has been experiencing breast engorgement. To relieve engorgement, the nurse
teaches the client to use which intervention before nursing her baby?
You Selected:
Express a small amount of breast milk.
A nurse encourages a postpartum client to discuss the childbirth experience. Which
client outcome is most appropriate for this client?
You Selected:
"The client demonstrates the ability to integrate the childbirth experience and
progress to the task of maternal role attainment."
Correct response:
"The client demonstrates the ability to integrate the childbirth experience and
progress to the task of maternal role attainment."
Explanation:
Discussing the childbirth experience helps the client acknowledge and understand what
happened during this event. The nurse should give the client a chance to ask questions
about the event and seek clarification, if needed. After the client discusses the event,
she may be able to shift the focus away from herself and begin the tasks that will help
her assume the maternal role. The nurse must determine the client's understanding of
her physical needs and those of her neonate after teaching and demonstrating care
techniques; discussing the childbirth experience won't help her to meet these needs.
Remediation:
Discharge Planning, Neonatal
Question 2 See full question
A nurse is teaching a client about hormonal contraceptive therapy. If a client misses
three or more pills in a row, the nurse should instruct the client to:
You Selected:
discard the pack, use an alternative contraceptive method until her period
begins, and start a new pack on the regular schedule.
Correct response:
discard the pack, use an alternative contraceptive method until her period
begins, and start a new pack on the regular schedule.
Question 3 See full question
A client is 9 days postpartum and breast-feeding her neonate. The client experiences
pain, redness, and swelling of her left breast and is diagnosed with mastitis. The nurse
teaching the client how to care for her infected breast should include which information?
You Selected:
, Use a warm moist compress over the painful area.
Correct response:
Use a warm moist compress over the painful area.
Explanation:
Warm, moist compresses will reduce inflammation and edema of the infected breast
tissue. The woman with mastitis should wear a proper fitting bra with good support.
Breast-feeding does not have to be interrupted. The client will also need to pump the
breast to keep the breast empty of milk and to ensure an adequate milk supply.
Adequate emptying of the affected breast helps prevent more bacteria from collecting in
the breast and may shorten the duration of the infection. Antibiotics must be taken for
the full course of therapy and not stopped when symptoms subside.
Remediation:
Question 4 See full question
Which measure included in the care plan for a client in the fourth stage of labor requires
revision?
You Selected:
Obtain an order for catheterization to protect the bladder from trauma.
Correct response:
Obtain an order for catheterization to protect the bladder from trauma.
Explanation:
Catheterization isn't routinely done to protect the bladder from trauma. It's done,
however, for a postpartum complication of urinary retention. The other options are
appropriate measures to include in the care plan during the fourth stage of labor.
Remediation:
Question 5 See full question
A 15-year-old client gives birth to a healthy neonate. The neonate's adolescent father
arrives on the unit demanding to see his baby. Both sets of grandparents are also
present and asking to see their grandchild. The newly hired nurse assigned to the
nursery should take which action?
You Selected:
Discuss the unit's policy with the charge nurse.
Correct response:
, Discuss the unit's policy with the charge nurse.
Explanation:
Remediation:
Question 6 See full question
After the first breastfeeding, the client asks the nurse, “How often should I try to
breastfeed?” What frequency should the nurse recommend?
You Selected:
every 2 to 3 hours for the first 48 hours
Correct response:
every 2 to 3 hours for the first 48 hours
Explanation:
Soon after giving birth, the client should breastfeed every 2 to 3 hours until her milk
supply is established.
Remediation:
Question 7 See full question
While assessing a primipara during the immediate postpartum period, the nurse plans to
use both hands to assess the client's fundus to:
You Selected:
promote uterine involution.
Correct response:
prevent uterine inversion.
Explanation:
Using both hands to assess the fundus is useful for the prevention of uterine inversion.
With one hand, the nurse should support the position of the lower uterus and cervix,
while palpating the fundus with the other hand.
Using both hands does not hasten or promote uterine involution, which lasts about 6
weeks from the time of childbirth.
Using both hands to assess the fundus will not hasten the puerperium period.
, Determining the size of the fundus may be important if the client is experiencing
excessive lochia because an enlarged fundus may be an indicator of retained blood
clots or placenta fragments. The nurse, though, does not need to use both hands to
determine this.
Remediation:
Question 8 See full question
The nurse from the nursery is bringing a newborn to a mother’s room. The nurse took
care of the mother yesterday and knows the mother and baby well. The nurse should
implement which action to ensure the safest transition of the infant to the mother?
You Selected:
Complete the hospital identification procedure with mother and infant.
Correct response:
Complete the hospital identification procedure with mother and infant.
Explanation:
Remediation:
Question 9 See full question
Which client statement indicates effective teaching about burping a breastfed neonate?
You Selected:
“When I switch to the other breast, I’ll burp the baby.”
Correct response:
“When I switch to the other breast, I’ll burp the baby.”
Explanation:
Remediation:
Question 10 See full question
During a home visit on the fourth postpartum day, a primiparous client tells the nurse
that she has been experiencing breast engorgement. To relieve engorgement, the nurse
teaches the client to use which intervention before nursing her baby?
You Selected:
Express a small amount of breast milk.
