Exam Review

A nurse is preparing to administer potassium chloride 30 mEq PO daily. The amount available is potassium chloride 20 mEq/15mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) .
Correct Answer:22.5 mL
A nurse is caring for a client who is 1 day postpartum following a cesarean birth.To prevent thrombophlebitis, the nurse should contribute which of the following interventions to the client’s plan of care?
A)
Have the client ambulate frequently in the hallway.
B)
Apply warm, moist soaks to the client’s lower legs.
C)
Keep the client on bed rest.
D)
Place pillows under the client’s knees while she is resting in bed.
In your patients who have sustained an episiotomy or a laceration, your nursing care would include? (Select all that apply.)
(SATA)
A)
Topical cream.
B)
Use sitz baths.
C)
Ice packs.
D)
Give tocolytics.
E)
Nothing.
A nurse is reinforcing discharge instructions for a client.At 4 weeks postpartum, the client should contact the provider for which of the following client findings?
A)
Sore nipple with cracks and fissures.
B)
Scant nonodorous white vaginal discharge.
C)
Uterine cramping during breastfeeding.
D)
Decreased response with sexual activity.

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Exam Review

A nurse is caring for a postpartum client who saturates a perineal pad in 10 minutes.Which of the following actions should the nurse take first?
A)
Check the client’s blood pressure.
B)
Observe the client.
C)
Massage the client’s fundus.
D)
Administer oxytocin.
A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client’s perineal pad.Which of the following actions should the nurse take first?
A)
Measure the client’s vital signs.
B)
Request the provider perform a vaginal examination.
C)
Check the client’s fundus.
D)
Feel for a full bladder.
A client who is 7 days postpartum calls the provider’s office and reports pain, swelling, and redness of her left calf.Besides the client seeing the provider, which of the following interventions should the nurse suggest?
A)
Massage the area.
B)
Elevate the leg.
C)
Apply cold compresses.
D)
Flex the knee while resting.
During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops.On data collection, 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)
An indication of a cervical or perineal laceration.
B)
Abnormally excessive lochia rubra flow.
C)
A normal postural discharge of lochia.
D)
Evidence of a possible vaginal hematoma.

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Exam Review

A nurse is reinforcing discharge teaching with a client who is 2 days postpartum and has a history of postpartum depression.Which of the following instructions should the nurse include?
A)
Stay home until one week after delivery.
B)
Sleep as much as possible.
C)
Return to work two weeks after delivery.
D)
Contact a crisis counselor once a week.
A new mother who is bottle feeding says that she is happy to not have to use birth control for several months after having a baby.What should the nurse say in response?
A)
You won’t need to use it for at least 6 months.
B)
Most people don’t need it for 3 months.
C)
You might ovulate within 27 days.
D)
That’s right.
After a client has a C-section she needs to get up and take short walks to prevent what?
A)
Hemorrhage.
B)
Blood clots.
C)
Breast engorgement.
D)
Rupture of amniotic membranes.
The nurse working in a women’s clinic admits a patient who is almost 6 weeks postpartum and describes a yellow-white vaginal drainage.The nurse interprets this as indicating what?
A)
Fungal infection.
B)
Expected lochia progression.
C)
Retained placenta.
D)
Bacterial infection.

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Exam Review

A nurse is assisting a client out of bed for the first time since delivery.The client becomes frightened when she passes a large amount of lochia.Which of the following responses should the nurse make?
A)
Urinary tract infections are associated with increased lochia.
B)
Lochia can pool in the vagina while you lie in bed.
C)
You might have retained fragments of your placenta.
D)
The amount of lochia increases during the postpartum period.
A nurse is reinforcing teaching with a client who is breastfeeding and has mastitis.Which of the following responses should the nurse make?
A)
Completely empty each breast at each feeding or use a pump.
B)
Nurse the infant only on the unaffected breast until resolved.
C)
Wear a tight-fitting bra until lactation has ceased.
D)
Limit the amount of time the infant nurses on each breast.
A nurse is caring for a client who just delivered a stillborn infant at 36 weeks gestation. Which of the following responses should the nurse make?
A)
I understand your grief. I lost a baby also.
B)
I have called for the chaplain to come and stay with you.
C)
You may hold your baby as long as you want.
D)
This is for the best. Your baby was very ill.
A nurse is caring for a client who is 2 weeks postpartum.The client tells the nurse, “I feel really down and sad lately.I have no energy and I feel like I’m going to cry.”. Which of the following actions should the nurse take first?
A)
Arrange for counseling to help the client cope with the stress of being a parent.
B)
Reinforce teaching about ways to increase rest and sleep.
C)
Request a prescription for an antidepressant medication.
D)
Use a postpartum depression-screening tool with the client.

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Exam Review

A nurse is collecting data from a client who is postpartum.Which of the following findings should alert the nurse to the possibility of a postpartum complication?
A)
Chills shortly following delivery.
B)
Heart rate 110/min.
C)
Urinary output 3,000 mL/12 hr.
D)
Fundus at umbilicus level.
A nurse is caring for a client who has unrelieved episiotomy pain 8 hr following delivery.Which of the following actions should the nurse take?
A)
Place a soft pillow under the client’s buttocks.
B)
Position a heating lamp toward the episiotomy.
C)
Prepare a warm sitz bath.
D)
Apply an ice pack to the perineum.
A nurse is collecting data from a client who gave birth 12 hr ago.The nurse notes the fundus is deviated to the right, boggy, and 2 cm above the umbilicus.Which of the following actions should the nurse take first?
A)
Insert an indwelling urinary catheter.
B)
Administer methylergometrine to the client.
C)
Obtain a stat hemoglobin level.
D)
Assist the client to void.
A nurse is assisting with the care of a postpartum client who is exhibiting tearfulness, insomnia, lack of appetite, and a feeling of letdown.Which of the following conditions are associated with these manifestations?
A)
Letting-go phase.
B)
Postpartum fatigue.
C)
Postpartum blues.
D)
Postpartum psychosis.

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Exam Review

A nurse is contributing to the plan of care for a client who is postpartum and has thrombophlebitis.Which of the following nursing interventions should the nurse recommend?
A)
Measure leg circumferences.
B)
Massage the affected extremity.
C)
Apply cold compresses to the affected extremity.
D)
Allow the client to ambulate.
A nurse is collecting data from a client who is 1 day postpartum.Which of the following findings requires immediate intervention by the nurse?
A)
Decreased urge to void.
B)
Displaced fundus from the midline.
C)
Fundal height below the umbilicus.
D)
Increased urine output.
A nurse is collecting data from a client who is 3 hr postpartum.The nurse notes that the client’s fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus.Which of the following actions should the nurse take?
A)
Insert a urinary catheter.
B)
Massage the fundus.
C)
Have the client urinate.
D)
Administer analgesia.
A nurse is caring for a client who is postpartum.Which of the following findings is an indication for the nurse to administer Rho(D) immune globulin?
A)
The client is Rh positive and the newborn is Rh negative.
B)
The client is Rh positive and the newborn is Rh positive.
C)
The client is Rh negative and the newborn is Rh negative.
D)
The client is Rh negative and the newborn is Rh positive.

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