Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer)Nursing Care of Women with Complications After Birth,100% CORRECT

TB Maternity and Pediatric Nursing 8e (by Leifer)Nursing Care of Women with Complications After Birth MULTIPLE CHOICE 1. What is the first sign of hypovolemic shock from postpartum hemorrhage? a. Cold, clammy skin b. Tachycardia c. Hypotension d. Decreased urinary output ANS: B Tachycardia is usually the first sign of inadequate blood volume. DIF: Cognitive Level: Knowledge REF: Page 248 OBJ: 2 TOP: Hypovolemic Shock KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. Although the nurse has massaged the uterus every 15 minutes, it remains flaccid, and the patient continues to pass large clots. What does the nurse recognize these signs indicate? a. Uterine atony b. Uterine dystocia c. Uterine hypoplasia d. Uterine dysfunction ANS: A Atony describes a lack of normal muscle tone. If the uterus is atonic, then muscle fibers are flaccid and will not compress bleeding vessels. DIF: Cognitive Level: Comprehension REF: PNaUgeRS2I5N0GTB.COM TOP: Atony KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. What should the nurses first action be when postpartum hemorrhage from uterine atony is suspected? a. Teach the patient how to massage the abdomen and then get help. b. Start IV fluids to prevent hypovolemia and then notify the registered nurse. c. Begin massaging the fundus while another person notifies the physician. d. Ask the patient to void and reassess fundal tone and location. ANS: C When the uterus is boggy, the nurse should immediately massage it until it becomes firm. DIF: Cognitive Level: Application REF: Page 250 OBJ: 6 TOP: Atony KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. The nurse assesses a boggy uterus with the fundus above the umbilicus and deviated to the side. What should the nurses next assessment be? a. Fullness of the bladder b. Amount of lochia c. Blood pressure d. Level of pain ANS: A Bladder distention can cause uterine atony. The uterus is massaged to firmness and then the bladder is emptied. DIF: Cognitive Level: Application REF: Page 251 TOP: Bladder Distention KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. Massage and putting the infant to the breast of a postpartum patient have been ineffective in controlling a boggy uterus. What will the nurse anticipate might be ordered by the physician? a. Ritodrine b. Magnesium sulfate c. Oxytocin d. Bromocriptine ANS: C Oxytocin (Pitocin) is the most common drug ordered to control uterine atony. DIF: Cognitive Level: Comprehension REF: Page 251 TOP: Oxytocin (Pitocin) for Hemorrhage KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. A 4-week postpartum patient with mastitis asks the nurse if she can continue to breastfeed. What is the nurses most helpful response? a. Stop breastfeeding until the infection clears. b. Pump the breasts to continue milk production, but do not give breast milk to the infant. c. Begin all feedings with the affected breast until the mastitis is resolved. d. Breastfeeding can continue unless there is abscess formation. ANS: D The woman with mastitis can continue to breastfeed unless an abscess forms. DIF: Cognitive Level: Application REF: Page 256 TOP: Mastitis and Breastfeeding KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. A woman had a vaginal delivery two days aNgUo RaSndINiGs TprBe.pCaOriMng for discharge. What will the nurse plan to teach the woman to report to help prevent postpartum complications? a. Fever b. Change in lochia from red to white c. Contractions d. Fatigue and irritability ANS: A Increased temperature is a sign of infection. The other choices are normal in the postpartum period. DIF: Cognitive Level: Application REF: Page 254 TOP: Puerperal Infections KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 8. One day after discharge, the postpartum patient calls the clinic complaining of a reddened area on her lower leg, temperature elevation of 37 C (99.8 F), rust-colored lochia, and sore breasts. What does the nurse suspect from these symptoms? a. Phlebitis b. Puerperal infection c. Late postpartum hemorrhage d. Mastitis ANS: A The complaints related to the leg are indicative of phlebitis. The other signs are normal in the postpartum patient. DIF: Cognitive Level: Analysis REF: Page 253 TOP: Phlebitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. Which statement indicates to the nurse on a postpartum home visit that the patient understands the signs of late postpartum hemorrhage? a. My discharge would change to red after it has been pink or white. b. If I have a postpartum hemorrhage, I will have severe abdominal pain. c. I should be alert for an increase in bright red blood. d. I would pass a large clot that was retained from the placenta. ANS: A When the nurse teaches the postpartum woman about normal changes in lochia, it is important to explain that a return to red bleeding after it has changed to pink or white may indicate a late postpartum hemorrhage. DIF: Cognitive Level: Comprehension REF: Page 252 TOP: Color Change in Lochia KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 10. During a postpartum assessment, a woman reports her right calf is painful. The nurse observes edema and redness along the saphenous vein in the right lower leg. Based on this finding, what does the nurse explain the probable treatment will involve? a. Anticoagulants for 6 weeks b. Application of ice to the affected leg c. Gentle massage of the affected leg d. Passive leg exercises twice a day ANS: A Anticoagulant therapy is continued with heparin or warfarin (Coumadin) for 6 weeks after birth to minimize the risk of embolism. DIF: Cognitive Level: Analysis REF: Page 253 TOP: Anticoagulant Therapy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: PharmNaUcRolSoIgNicGaTl BT.hCeOraMpies 11. What statement by the patient leads the nurse to determine a woman with mastitis understands treatment instructions? a. I will apply cold compresses to the painful areas. b. I will take a warm shower before nursing the baby. c. I will nurse first on the affected side. d. I will empty the affected breast every 8 hours. ANS: B Moist heat promotes blood flow to the area, comfort, and complete emptying of the breast. DIF: Cognitive Level: Comprehension REF: Page 256 TOP: Mastitis KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 12. What is the best response to a postpartum woman who tells the nurse she feels tired and sick all of the time since I had the baby 3 months ago? a. This is a normal response for the body after pregnancy. Try to get more rest. b. Ill bet you will snap out of this funk real soon. c. Why dont you arrange for a babysitter so you and your husband can have a night out? d. Lets talk about this further. I am concerned about how you are feeling. ANS: D If a postpartum woman seems depressed, it is important to explore her feelings to determine if they are persistent and pervasive. DIF: Cognitive Level: Application REF: Page 257 OBJ: 6 | 7 TOP: Depression KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 13. The nurse is caring for a woman who had a cesarean birth yesterday. Varicose veins are visible on both legs. What nursing action is the most appropriate to prevent thrombus formation? a. Have the woman sit in a chair for meals. b. Monitor vital signs every 4 hours and report any changes. c. Tell the woman to remain in bed with her legs elevated. d. Assist the woman with ambulation for short periods of time. ANS: D Early ambulation and range-of-motion exercises are valuable aids to prevent thrombus formation in the postpartum woman. DIF: Cognitive Level: Application REF: Page 253 TOP: Thrombus Prevention KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 14. Five days after a spontaneous vaginal delivery, a woman comes to the emergency room because she has a fever and persistent cramping. What does the nurse recognize as the possible cause of these signs and symptoms? a. Dehydration b. Hypovolemic shock c. Endometritis d. Cystitis ANS: C Fever after 24 hours following delivery is suggestive of an infection. Severe cramping and fever are manifestations of endometritis. DIF: Cognitive Level: Analysis REF: Page 254 OBJ: 2 TOP: Puerperal Infections KEY: Nursing Process Step: Data Collection NURSINGTB.COM MSC: NCLEX: Physiological Integrity: Physiological Adaptation 15. At her 6-week postpartum checkup, a woman mentions to the nurse that she cannot sleep and is not eating. She feels guilty because sometimes she believes her infant is dead. What does the nurse recognize as the cause of this womans symptoms? a. Bipolar disorder b. Major depression c. Postpartum blues d. Postpartum depression ANS: B Major depression is a disorder characterized by deep feelings of worthlessness, guilt, serious sleep and appetite disturbances, and sometimes delusions about the infant being dead. DIF: Cognitive Level: Analysis REF: Page 257 TOP: Major Depression KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 16. Three weeks after delivering her first child, a woman tells the nurse, I waited so long for this baby and now that she is here, I cant believe how different my life is from what I expected. What is the best nursing response to the womans statement? a. How is your partner adjusting to the change? b. I hear this from a lot of first-time mothers. c. Have you told anyone else about your feelings? d. Tell me how things are different. ANS: D The nurse may help the woman by being a sympathetic listener. The nurse should elicit the new mothers feelings about motherhood and her infant. DIF: Cognitive Level: Application REF: Page 257 TOP: Disorders of Mood KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 17. After a prolonged labor, a woman vaginally delivered a 10 pound, 3 ounce infant boy. What complication should the nurse be alert for in the immediate postpartum period? a. Cervical laceration b. Hematoma c. Endometritis d. Retained placental fragments ANS: B Delivering a large infant and a prolonged labor are risk factors for hematoma formation. DIF: Cognitive Level: Analysis REF: Page 251 TOP: Hematoma KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 18. A woman has had persistent lochia rubra for 2 weeks after her delivery and is experiencing pelvic discomfort. What does the nurse explain is the usual treatment for subinvolution? a. Uterine massage b. Oxytocin infusion c. Dilation and curettage d. Hysterectomy ANS: C Medical treatment for subinvolution is selected to correct the cause. Treatment may include dilation of the cervix and curettage to remove retained placental fragments from the uterine wall. DIF: Cognitive Level: Knowledge REF: PageN2U52RSINGTB.COM TOP: Subinvolution of the Uterus KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. The 1-day postpartum patient shows a temperature elevation, cough, and slight shortness of breath on exertion. What action should the nurse implement based on these symptoms? a. Notify the charge nurse of a possible upper respiratory infection. b. Notify the physician of a possible pulmonary embolism. c. Document expected postpartum mucous membrane congestion. d. Medicate with antipyretic remedy for elevated temperature. ANS: B Symptoms of early pulmonary embolism may not be dynamic. The cough with shortness of breath and temperature elevation is a clue to this possible complication. DIF: Cognitive Level: Application REF: Page 253 TOP: Pulmonary Embolus KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 20. While caring for a postpartum patient who had a vaginal delivery yesterday, the nurse assesses a firm uterine fundus and a trickle of bright blood. How does the nurse most likely feel and react to this finding? a. Concerned and reports a probable cervical laceration b. Attentive and massages the uterus to expel retained clots c. Distressed and reports a possible clotting disorder d. Satisfied with the normal early postpartum finding ANS: A The bright trickle of blood with a firm uterus suggests a cervical laceration. DIF: Cognitive Level: Application REF: Page 251 TOP: Laceration KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk 21. The nurse assesses a positive Homans sign when the patients leg is flexed and foot sharply dorsiflexed. Where does the patient report that the pain is felt? a. Groin b. Achilles tendon c. Top of the foot d. Calf of the leg ANS: D A pain in the calf of the leg when the leg is flexed and the foot is dorsiflexed is a positive Homans sign. Homans sign is suggestive of a deep vein thrombosis. DIF: Cognitive Level: Comprehension REF: Page 253 TOP: Homans Sign KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 22. The new mother who had a vaginal delivery yesterday has a white blood cell count of 30,000 cells/dL. What action should the nurse implement? a. Notify the charge nurse of a possible infection. b. Prepare to put the patient in isolation. c. Have the infant removed from the room and returned to the nursery. d. Assess the patient further. ANS: D The patient should be assessed further for other signs of infection because a white blood cell (WBC) count of 20,000 to 30,000 cells/dL is normal in the early postpartum period. DIF: Cognitive Level: Analysis REF: Page 25N4URSINGTB.COM TOP: Elevated WBC KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 23. A postpartum patient experiences anaphylactic shock. What is the most likely cause? a. Pulmonary embolism b. Hypertension c. Allergy d. Blood clotting disorder ANS: C Anaphylactic shock is caused by allergic responses to drugs administered. Cardiogenic shock may be caused by pulmonary embolism or hypertension. Hypovolemic shock could be caused by blood clotting disorders. DIF: Cognitive Level: Comprehension REF: Page 247 TOP: Shock KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 24. A woman is prescribed Coumadin (warfarin) to treat deep vein thrombosis. What will the nurse instruct this woman is the antidote for warfarin overdose? a. Vitamin A b. Vitamin B c. Vitamin E d. Vitamin K ANS: D The antidote for warfarin overdose is vitamin K. DIF: Cognitive Level: Knowledge REF: Page 253 TOP: Warfarin KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies MULTIPLE RESPONSE 25. A nurse is discussing risk factors for postpartum shock with a childbirth preparation class. What will the nurse include in this education session? (Select all that apply.) a. Hypertension b. Blood clotting disorders c. Anemia d. Infection e. Postpartum hemorrhage ANS: B, C, D, E Hypertension is not a cause for postpartum shock; all the other options can cause shock. DIF: Cognitive Level: Application REF: Page 247 TOP: Postpartum Shock KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 26. The nurse assesses the perineal pad placed on a 3-hour postdelivery patient and finds that there is no lochia on it. What would the nurse expect to find on further assessment? (Select all that apply.) a. A firm fundus the size of a grapefruit b. A full bladder c. Retained placental fragments d. Vital signs indicative of shock e. A soft, boggy fundus ANS: B, E Large clots that form in a flaccid uterus can obstruct the flow of lochia. A full bladder is a major cause of a uterus that is boggy. NURSINGTB.COM DIF: Cognitive Level: Analysis REF: Page 250 TOP: Cessation of Lochia KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 27. The nurse instructs the postpartum patient that her nutritional intake should include which food(s) particularly supportive to healing? (Select all that apply.) a. Legumes b. Potatoes and pasta c. Citrus fruits d. Rice e. Cantaloupe ANS: A, C, E Legumes and foods containing vitamin C are conducive to healing. Starches are not. DIF: Cognitive Level: Comprehension REF: Page 255 TOP: Foods Conducive to Healing KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 28. What will the nurse teach a nursing mother to do to reduce the risk of mastitis? (Select all that apply.) a. Limit fluid intake to 1 liter per day. b. Empty both breasts with each feeding. c. Take warm showers. d. Wear a supportive bra. e. Pump breasts to ensure emptying. ANS: B, C, D, E Nursing mothers should take in about 3 liters of fluid a day. All the other options are interventions to reduce the risk of mastitis and milk accumulation in the breast. DIF: Cognitive Level: Comprehension REF: Page 256 TOP: Reduction of the Risk of Mastitis KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 29. A woman is diagnosed with a urinary tract infection in the postpartum period. What foods can the nurse encourage to increase the acidity of urine? (Select all that apply.) a. Apricots b. Cranberry juice c. Plums d. Prunes e. Apples ANS: A, B, C, D Apricots, cranberry juice, plums, and prunes can increase the acidity of urine. Apples are not considered to increase acidity of urine. DIF: Cognitive Level: Comprehension REF: Page 254 OBJ: 4 TOP: Urinary Tract Infection KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 30. A postpartum patient is experiencing hypovolemic shock. What interventions can the nurse anticipate? (Select all that apply.) a. Provision of IV fluids b. Placement of an indwelling Foley catheter c. Assessment of oxygen saturation d. Administration of anticoagulants e. Blood transfusion ANS: A, B, C, E NURSINGTB.COM Medical management for the patient experiencing hypovolemic shock includes stopping blood loss, giving IV fluids to maintain circulating volume and replace fluids, giving blood transfusions to replenish erythrocytes, and assessment of oxygen saturation. Anticoagulants would not be given. DIF: Cognitive Level: Application REF: Page 248 TOP: Hypovolemic Shock KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease COMPLETION 31. The nurse weighs a saturated perineal pad and finds it to weigh 15 grams. The nurse is aware that this indicates a blood loss of mL. ANS: 15 The weight of 1 g in a perineal pad is equal to 1 mL of blood loss. DIF: Cognitive Level: Comprehension REF: Page 248 TOP: Weighing Perineal Pad KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 32. The nurse explains that a slower than expected return of the uterus to the nonpregnant state is called . ANS: subinvolution Subinvolution is the term applied to the uteruss slower than expected return to a nonpregnant state. DIF: Cognitive Level: Knowledge REF: Page 252 TOP: Subinvolution KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 33. A(n) is a collection of blood within the tissues. ANS: hematoma A hematoma is a collection of blood within the tissues. DIF: Cognitive Level: Knowledge REF: Page 251 TOP: Hematoma KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation