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TEST BANK FOR NCLEX RN ATI Maternal Newborn Nursing EDITION Postpartum Nursing Care
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TEST BANK FOR NCLEX RN ATI Maternal Newborn Nursing EDITION Postpartum Nursing Care Postpartum Adaptation
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TEST BANK FOR NCLEXRN ATI Maternal Newborn
Nursing EDITION
Postpartum Nursing Care
CERTIFEDNURSE
,A nurse is performing a fundal assessment for a client who is 3
days postpartum and observes the perineal pad for lochia. The pad
is saturated approximately 12cm with lochia that is bright red and
contains small clots. Which of the following should the nurse
document?
A. Moderate lochia rubra
B. Excessive lochia serosa
C. Light lochia rubrua
D. Scant lochia serosa
A
During ambulation to the bathroom a postpartum client
experiences a gush of dark red blood that soon stops. On
assessment, a nurse find 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. Evidence of a possible vaginal hematoma
B. An indication of a cervical or perineal laceration
C. A normal postural discharge of lochia
D. Abnormally excessive lochia rubra flow
C
A nurse is completing postpartum discharge teaching to a client
who had no immunity to varicella and was given the varicella
vaccine. Which of the following statements by the client indicates
understanding of the teaching?
A. I will need to use contraception for 3 months before considering
pregnancy.
B. I need a second vaccination at my postpartum visit
C. I was given the vaccine because my baby is O-positive
D. I will be tested in 2 months to see if I have developed immunity
B
A nurse is assessing a postpartum client for fundal height, location,
and consistency. The fundus is noted to be displaced laterally to the
,right, and there is uterine atony. The nurse should identify which
of the following conditions as the cause of uterine atony.
A. Poor involution
B. Urinary retention
C. Hemorrhage
D. Infection
B
A nurse is providing education to a client who is 2 hours
postpartum and has perineal laceration. Which of the following
information should the nurse include? (Select all)
A. Use a perineal squeeze bottle to cleanse the perineum
B. Sit on the perineum while resting. in bed
C. Apply a topical anesthetic cream or spray to the perineum
D. Wipe the perineum thoroughly with a back and forth motion
E. Apply cold or ice packs to perineum
A, C, E
A nurse concludes that the parent of a newborn is not showing
positive indications of parent-infant bonding. The parent appears
very anxious and nervous when asked to bring the newborn to the
other parent. Which of the following actions should the nurse use to
promote parent-infant bonding?
A. Hand the parent the newborn, and suggest that they change the
diaper
B. Ask the parent why they are so anxious and nervous
C. Tell the parent they will grow accustomed to the newborn
D. Provide education about infant care when the parent is present
D
A client in the early postpartum period is very excited and
talkative. They repeatedly tell the nurse every detail of the labor
and birth. The client will not stop talking, the nurse is having
difficulty completing the postpartum assessments. Which of the
following action should the nurse take?
, A. Come back later when the client is more cooperative
B. Give client time to express feelings
C. Tell the client they need to be quiet so the assessment can be
completed
D. Redirect the clients focus so they will become quiet
B
A nurse is caring for a client who is one day postpartum. The nurse
is assessing for maternal adaptation and parent-infant bonding.
Which of the following behaviors by the client indicates a need for
the nurse to intervene? (Select all)
A. Demonstrates apathy when the newborn cries
B. Touches the newborn and maintains close physical proximity
C. Views the newborn's behavior as uncooperative during diaper
changing
D. Identifies and relates newborn's characteristics to those family
members
E. Interprets the newborn's behavior as meaningful and a way of
expressing needs.
A, C
A nurse is caring for a client who is 2 days postpartum. The client
states "My 4 year old son was toilet trained and now he is
frequently wetting himself." Which of the following statements
should the nurse provide to the client?
A. Your son was probably not ready for toilet training and should
wear training pants
B. Your son is showing an adverse sibling response
C. Your son may need counseling
D. You should try sending your son to preschool to resolve the
behavior
B
A nurse in the delivery room is planning to promote parent-infant
bonding for a client who just delivered. Which of the following is a
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