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Saunders nclex postpartum questions
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Saunders nclex postpartum questions
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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."
, Saunders NCLEX Postpartum Questions
2.
"You will need to feed your newborn by nasogastric tube feeding."
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?
, Saunders NCLEX Postpartum Questions
1.
"We want to attend a support group."
2.
"We never want to try to have a baby again."
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.
, Saunders NCLEX Postpartum Questions
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."
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.
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