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HIGH-RISK POSTPARTUM NCLEX EXAM 3 QUESTIONS
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HIGH-RISK POSTPARTUM NCLEX EXAM 3 QUESTIONS
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HIGH-RISK POSTPARTUM NCLEX EXAM 3QUESTIONS
3
The nurse assesses a 2-day postpartum, breastfeeding client. The nurse notes blood on
the mother's breast pad and a crack on the mother's nipple. Which of the following
actions should the nurse perform at this time?
1. Advise the woman to wash the area with soap to prevent mastitis.
2. Provide the woman with a tube of topical lanolin.
3. Remind the woman that the baby can become sick if he drinks the blood.
4. Get the woman an order for a topical anesthetic.
1
The nurse administers RhoGAM to a postpartum client. Which of the following is the
goal of the medication?
1. Inhibit the mother's active immune response.
2. Aggressively destroy the Rh antibodies produced by the mother.
3. Prevent fetal cells from migrating throughout the mother's circulation.
4. Change the maternal blood type to Rh-positive.
2
Which of the following comments suggest that a client whose baby was born with a
congenital defect is in the bargaining phase of grief?
1. "I hate myself. I caused my baby to be sick."
2. "I'll take him to a specialist. Then he will get better."
3. "I can't seem to stop crying."
4. "This can't be happening.
2
,A client is 1 day post-cesarean section with spinal anesthesia. Even though the nurse
advised against it, the client has had the head of her bed in high Fowler's position since
delivery. Which of the following complications would the nurse expect to see in relation
to the client's action?
1. Postpartum hemorrhage.
2. Severe postural headache.
3. Pruritic skin rash.
4. Paralytic ileus.
2A breastfeeding client is being seen in the emergency department with a hard, red,
warm nodule in the upper outer quadrant of her left breast. Her vital signs are: T
104.6°F, P 100, R 20, and BP 110/60. She has a recent history of mastitis and is crying
in pain. Which of the following nursing diagnoses is highest priority?
1. Ineffective breastfeeding.
2. Infection.
3. Ineffective individual coping.
4. Pain.
1
A nurse massages the atonic uterus of a woman who delivered 1 hour earlier. The
nurse identifies the nursing diagnosis: Risk for injury related to uterine atony. Which of
the following outcomes indicates that the client's condition has improved?
1. Moderate lochia flow.
2. Decreased pain level.
3. Stable blood pressure.
4. Fundus above the umbilicus.
1
Intermittent positive pressure boots have been ordered for a client who had an
emergency cesarean section. Which of the following is the rationale for that order?
, 1. Postpartum clients are at high risk for thrombus formation.
2. Post-cesarean clients are at high risk for fluid volume deficit.
3. Postpartum clients are at high risk for varicose vein development.
4. Post-cesarean clients are at high risk for poor milk ejection reflex.
1
A client who received an epidural for her operative delivery has vomited twice since the
surgery. Which of the following prn medications ordered by the anesthesiologist should
the nurse administer at this time?
1. Reglan (metoclopramide).
2. Demerol (meperidine).
3. Seconal (secobarbital).
4. Benadryl (diphenhydramine).
3
A woman has just had a low forceps delivery. For which of the following should the
nurse assess the woman during the immediate postpartum period?
1. Infection.
2. Bloody urine.
3. Heavy lochia.
4. Rectal abrasions.
1
A postpartum woman has been diagnosed with postpartum psychosis. Which of the
following is essential to be included in the family teaching for this client?
1. The woman should never be left alone with her infant.
2. Symptoms rarely last more than one week.
3. Clinical response to medications is usually poor.
4. The woman must have her vitals assessed every two days.
1
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