Nur 160 Exam- 247 Questions with Verified 100% Correct Answers
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Course
Nur 160
Institution
Nur 160
When the nurse is assessing a postpartum client approximately 6 hours after birth,
which finding would warrant further investigation?
1. voiding of 350 cc
2. deep red, fleshy-smelling lochia
3. blood pressure 90/50 mm Hg
4. profuse sweating - Answer 3. blood pressure 90/50 mm Hg
Nur 160 Exam- 247 Questions with Verified
100% Correct Answers
When the nurse is assessing a postpartum client approximately 6 hours after birth,
which finding would warrant further investigation?
1. voiding of 350 cc
2. deep red, fleshy-smelling lochia
3. blood pressure 90/50 mm Hg
4. profuse sweating - Answer 3. blood pressure 90/50 mm Hg
In most instances of postpartum hemorrhage, blood pressure and cardiac output remain
increased because of the compensatory increase in heart rate. Thus, a decrease in blood
pressure and cardiac output are not expected changes during the postpartum period.
Early identification is essential to ensure prompt intervention. Deep red, fleshy-smelling
lochia is a normal finding 6 hours postpartum. Voiding in small amounts such as less
than 150 cc would indicate a problem, but 350 cc would be appropriate. Profuse
sweating also is normal during the postpartum period.
A nurse is making a home visit to a postpartum woman who gave birth to a healthy
newborn 4 days ago. The woman's breasts are swollen, hard, and tender to the touch.
The nurse documents this finding as:
,Engorgement is the process of swelling of the breast tissue as a result of an increase in
blood and lymph supply as a precursor to lactation (Figure 15.4). Breast engorgement
usually peaks in 3 to 5 days postpartum and usually subsides within the next 24 to 36
hours (Chapman, 2011). Engorgement can occur from infrequent feeding or ineffective
emptying of the breasts and typically lasts about 24 hours. Breasts increase in
vascularity and swell in response to prolactin 2 to 4 days after birth. If engorged, the
breasts will be hard and tender to touch. Involution refers to the process of the uterus
returning to its prepregnant state. Mastitis refers to an infection of the breasts.
Engrossment refers to the bond that develops between the father and the newborn.
A nurse is assessing a client during the postpartum period. Which findings indicate
normal postpartum adjustment? Select all that apply.
1. abdominal pain
2. nondistended abdomen
3. active bowel sounds
4. tender abdomen
5. passing gas - Answer 2. nondistended abdomen
3. active bowel sounds
5. passing gas
Finding active bowel sounds, verification of passing gas, and a nondistended abdomen
are normal assessment results. The abdomen should be nontender and soft. Abdominal
pain is not a normal assessment finding and should be immediately looked into.
A nurse is caring for a non-breastfeeding client in the postpartum period. The client
reports engorgement. What suggestion should the nurse provide to alleviate breast
discomfort?
1. Apply warm compresses.
,2. Express milk frequently.
3. Wear a well-fitting bra.
4. Apply hydrogel dressing. - Answer 3. Wear a well-fitting bra.
The nurse should suggest the client wear a well-fitting bra to provide support and help
alleviate breast discomfort. Application of warm compresses and expressing milk
frequently are suggested to alleviate breast engorgement in breastfeeding clients.
Hydrogel dressings are used prophylactically in treating nipple pain.
The nurse assesses a postpartum client's discharge as being moderate in amount and
red in color. How should the nurse document the appearance of the lochia?
Lochia that is red in color, or bloody, is termed lochia rubra. Lochia alba is colorless flow
that occurs around postpartum day 10. Lochia serosa is pink or brown in color and
appears around postpartum day 4. Lochia normalia is not a term used to describe lochia.
Which condition should the nurse look for in the client's history that may explain an
increase in the severity of afterpains?
, Multiple gestation, breastfeeding, multiparity, and conditions that cause overdistention
of the uterus will increase the intensity of afterpains. Bottle-feeding and diabetes aren't
directly associated with increasing severity of afterpains, unless the client has delivered
a macrosomic neonate.
A nurse is to care for a client during the postpartum period. The client reports pain and
discomfort in her breasts. What signs should a nurse look for to find out if the client has
engorged breasts? Select all that apply.
1. Breasts are hard.
2. Breasts are tender.
3. Nipples are fissured.
4. Nipples are cracked.
5. Breasts are soft. - Answer 1. Breasts are hard.
2. Breasts are tender.
Engorged breasts are hard and tender, and the nurse should assess for these signs.
Improper positioning of the infant on the breast, not engorged breasts, results in
cracked, blistered, fissured, bruised, or bleeding nipples in the breastfeeding woman.
The night shift LPN is checking on a woman who had a cesarean birth with spinal
morphine injection anesthesia early that morning. The nurse counts a respiratory rate of
8 per minute. What should the nurse do first?
1. perform bag-to-mouth rescue breathing at a rate of 12 per minute
2. awaken the woman and instruct her to breathe more rapidly
3. administer naloxone per the preprinted orders
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