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Saunders Nclex Postpartum Questions Latest Update 2024/2025
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Saunders Nclex Postpartum Questions Latest Update 2024/2025
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Saunders NCLEX Postpartum Questions1. A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be
administered before discharge. The nurse provides which information to the client about the vaccine? Select all that
apply.
1.
Breast-feeding needs to be stopped for 3 months.
2.
Pregnancy needs to be avoided for 1 to 3 months.
3.
The vaccine is administered by the subcutaneous route.
4.
Exposure to immunosuppressed individuals needs to be avoided.
5.
A hypersensitivity reaction can occur if the client has an allergy to eggs.
6.
The area of the injection needs to be covered with a sterile gauze for 1 week.: 2, 3, 4, 5
Rubella vaccine is administered to women who have not had rubella or women who are not serologically immune
The vaccine may be administered in the immediate postpartum period to prevent the possibility of contracting
rubella in future pregnancies. The live attenuated rubella virus is not communicable in breast milk; breast-feeding
does not need to be stopped. The client is counseled not to become pregnant for 1 to 3 months after immunization
as specified by the health care provider because of a possible risk to a fetus from the live virus vaccine; the client
must be using effective birth control at the time of the immunization. The client should avoid contact with
immunosuppressed individuals because of their low immunity toward live viruses and because the virus is shed in
the urine and other body fluids. The vaccine is administered by the subcutaneous route. A hypersensitivity reaction
can occur if the client has an allergy to eggs because the vaccine is made from duck eggs. There is no useful or
necessary reason for covering the area of the injection with a sterile gauze.
2. The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection
regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available
Which response should the nurse make to the client?
1.
"You will need to bottle-feed your newborn."
2.
"You will need to feed your newborn by nasogastric tube feeding."
, Saunders NCLEX Postpartum Questions
3.
"You will be able to breast-feed for 6 months and then will need to switch to bottle-feeding."
4.
"You will be able to breast-feed for 9 months and then will need to switch to bottle-feeding.": 1
Perinatal transmission of human immunodeficiency virus (HIV) can occur during the antepartum period, during
labor and birth, or in the postpartum period if the mother is breast-feeding. Clients who have HIV are advised not
to breast-feed. There is no physiological reason why the newborn needs to be fed by nasogastric tube.
3. A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together
holding and touching the baby. Which statement by the nurse would further assist the family in their initial period of
grief?
1.
"What can I do for you?"
2.
"Now you have an angel in heaven."
3.
"Don't worry, there is nothing you could have done to prevent this from happening."
4.
"We will see to it that you have an early discharge so that you don't have to be reminded of this experience.": 1
When a loss or death occurs, the nurse should ensure that parents have been honestly told about the situation by
their health care provider or others on the health care team. It is important for the nurse to be with the parents at
this time and to use therapeutic communication techniques. The nurse must also consider cultural and religious
practices and beliefs. The correct option provides a supportive, giving, and caring response. Options 2, 3, and 4 are
blocks to communication and devalue the parents' feelings.
4. The nurse in a maternity unit is providing emotional support to a client and her husband who are preparing to be
discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a
component of the normal grieving process?
1.
"We want to attend a support group."
2.
"We never want to try to have a baby again."
, Saunders NCLEX Postpartum Questions
3.
"We are going to try to adopt a child immediately."
4.
"We are okay, and we are going to try to have another baby immediately.": 1
A support group can help the parents work through their pain by nonjudgmental sharing of feelings. The correct
option identifies a statement that would indicate positive, normal grieving. Although the other options may
indicate reactions of the client and significant other, they are not specifically a part of the normal grieving process.
5. The nurse evaluates the ability of a hepatitis B-positive mother to provide safe bottle-feeding to her newborn during
postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease
transmission to the newborn?
1.
The mother requests that the window be closed before feeding.
2.
The mother holds the newborn properly during feeding and burping.
3.
The mother tests the temperature of the formula before initiating feeding.
4.
The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves
before feeding.: 4
Hepatitis B virus is highly contagious and is transmitted by direct contact with blood and body fluids of infected
persons. The rationale for identifying childbearing clients with this disease is to provide adequate protection of
the fetus and the newborn, to minimize transmission to other individuals, and to reduce maternal complications.
The correct option provides the best evaluation of maternal understanding of disease transmission. Option 1 will
not affect disease transmission. Options 2 and 3 are appropriate feeding techniques for bottle-feeding, but do not
minimize disease transmission for hepatitis B.
6. The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery.
Which statement made by the client indicates a need for further instruction?
1.
"I will begin abdominal exercises immediately."
2.
"I will notify the health care provider if I develop a fever."
, Saunders NCLEX Postpartum Questions
3.
"I will turn on my side and push up with my arms to get out of bed."
4.
"I will lift nothing heavier than my newborn baby for at least 2 weeks.": 1
A cesarean delivery requires an incision made through the abdominal wall and into the uterus. Abdominal
exercises should not start immediately after abdominal surgery; the client should wait at least 3 to 4 weeks
postoperatively to allow for healing of the incision. Options 2, 3, and 4 are appropriate instructions for the client
after a cesarean delivery.
7. After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn infant
briefly with her fingertips. What should the nurse do to help the woman process the delivery?
1.
Encourage the mother to breast-feed soon after birth.
2.
Support the mother in her reaction to the newborn infant.
3.
Tell the mother that it is important to hold the newborn infant.
4.
Document a complete account of the mother's reaction on the birth record.: 2
Precipitous labor is labor that lasts 3 hours or less. Women who have experienced precipitous labor often describe
feelings of disbelief that their labor progressed so rapidly. To assist the client to process what has happened, the
best option is to support the client in her reaction to the newborn infant. Options 1, 3, and 4 do not acknowledge
the client's feelings.
8. The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy
with a placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated
with placenta previa?
1. Infection
2.
Hemorrhage
3.
Chronic hypertension
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