The nurse is teaching a bottle-feeding mother how to manage engorgement when she gets home. Which of the following statements indicates a lack of understanding by the mother on this topic?
A.I can apply ice packs over my bra to my breasts for 15-20 minutes as needed for pain. B.Breast engorgement ...
NUR 230 Exam 2 Clicker Questions and
Answers
The nurse is teaching a bottle-feeding mother how to manage engorgement when she
gets home. Which of the following statements indicates a lack of understanding by the
mother on this topic?
A.I can apply ice packs over my bra to my breasts for 15-20 minutes as needed for pain.
B.Breast engorgement usually occurs about 72 to 96 hours after birth.
C.If I get engorged, I should place fresh green cabbage leaves over my breasts and
replace the leaves when they are wilted.
D.Running warm water over my breasts or expressing milk will help if my breasts get
overly full. ✅D.Running warm water over my breasts or expressing milk will help if my
breasts get overly full.
Reliable indicators of impending shock from early postpartum hemorrhage include all of
the following EXCEPT:
A.Pulse
B.Respirations
C.Blood pressure
D.Urinary output
E.Level of consciousness ✅C.Blood pressure
If a postpartum woman complains of extreme perineal pain, especially after having
received pain medication, the FIRST action by the nurse should be:
A.Notify the provider
B.Apply an ice pack to the perineum
C.Assess the perineum
D.Check the client's vital signs and fundus. ✅C.Assess the perineum
Upon examining a patient on day 2 after spontaneous vaginal delivery, a nurse finds the
perineal pad to be completely saturated with bright red blood over the last 15 minutes.
The priority in this scenario is:
A.Start a second intravenous line of Normal Saline.
B.Notify the primary health care provider.
C.Massage the fundus
Assess vital signs ✅C.Massage the fundus
(Uterine atony causing the bleeding so check fundus first- if not firm, massage it)
***Blood loss of delivery is replenished by all of the following EXCEPT:
A.Reduction in maternal vascular bed by elimination of uteroplacental circulation
B.Loss of placental endocrine function that removes the stimulus for vasodilation
,C.Reduction of intravascular fluid through dehydration in labor
D.Mobilization of extravascular water stored during pregnancy to increase plasma
volume ✅C.Reduction of intravascular fluid through dehydration in labor
(Want to mobilize and increase intravascular fluid not REDUCE it)
Which of the following information regarding postpartum women's bladder and bowel
patterns is FALSE?
A.The mother should void spontaneously within 6 to 8 hours after giving birth.
B.A volume of at least 150 mL is expected for each voiding.
C.All postpartum women are at risk for constipation.
D.Rectal suppositories and enemas may be safely used by all clients in the postpartum
period. ✅D.Rectal suppositories and enemas may be safely used by all clients in the
postpartum period.
(No if 3 or 4 laceration)
Which of the following types of birth control are contraindicated after hospital discharge
for the breastfeeding mother in the early postpartum period (1st 6 weeks)? SATA.
A.Condoms and spermicide
B.Depo Provera Injection
C.Oral Contraceptives
D.Abstinence
E.Lactational amenorrhea
F.Mirena IUD ✅C.Oral Contraceptives
F.Mirena IUD
***The nurse recognizes all of the following PP changes are normal EXCEPT:
A.Low grade fever (<100.2) in the first 24 hours
B.Profuse night-time sweating in the first few days postpartum
C.WBC's of 40,000/mm3
D.Intense shivering in the first hour postpartum without feeling cold ✅C.WBC's of
40,000/mm3
(should be less than 30,000)*****
The nurse is teaching a postpartum mother about skin changes in the postpartum
period. The nurse recognizes the mother needs additional teaching when the mother
states:
A.My stretch marks should fade but probably will not disappear completely.
B.I will have some hair loss for the first 12 months postpartum.
, C.The darker pigmentations I have over my cheeks and forehead usually disappears in
the PP period but may persist.
D.The stripe on my abdomen may or may not disappear. ✅B.I will have some hair loss
for the first 12 months postpartum.
(hair loss only for about 3 months)
Which postpartum clients require Rhogam. SATA
A.Mother who is O+, infant is AB+
B.Mother who is A-, infant is A+
C.Mother who is B-, infant is B-
D.Mother who is AB-, infant is unknown, and the father is B-
E.Mother who is B- status post miscarriage at 8 weeks.
F.Mother who is O+, infant is O- ✅B.Mother who is A-, infant is A+
D.Mother who is AB-, infant is unknown, and the father is B-
E.Mother who is B- status post miscarriage at 8 weeks.
A nurse receives report on four mother and baby couplets. Which client should the
nurse assess first?
A.A mother status post C/S 8 hours ago requesting pain medication. The baby is in the
NBN.
B.A mother who slept uninterrupted for 8 hours who reports a saturated perineal pad.
Infant is at the breast.
C.A mother who calls out to report that her infant's hands and feet are cyanotic.
D.A mother who calls out stating that an employee without the MBU ID badge is going
to take her NB for an X-Ray. ✅D.A mother who calls out stating that an employee
without the MBU ID badge is going to take her NB for an X-Ray.
Upon examining a patient on day 2 after spontaneous vaginal delivery, a nurse finds the
perineal pad to be completely saturated with bright red blood over the last 30 minutes.
The priority in this scenario is:
1.Start a second intravenous line of Normal Saline.
2.Notify the primary health care provider.
3.Massage the fundus
4.Assess vital signs. ✅3.Massage the fundus
With the completion of the THIRD stage of labor/beginning of the Fourth stage, there
are many necessary nursing interventions. Select all that apply.
A.Massage the fundus
B.Prepare for delivery of the placenta
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