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Saunders NCLEX Postpartum Questions Exam Questions & Answers, With Rationales
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Saunders NCLEX Postpartum Questions Exam Questions & Answers, With Rationales-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? Se...

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  • December 1, 2022
  • September 27, 2024
  • 51
  • 2024/2025
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Saunders NCLEX Postpartum Questions Exam
Questions & Answers
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.

,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."

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.

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.

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."

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.

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.

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.

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.

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