Practice With Maternal And Child Health Nursing NCLEX Test

2.

The nurse assesses the postpartum vaginal discharge (lochia) on four clients. Which of the following assessments would warrant notification of the physician?

A dark red discharge on a 2-day postpartum client
A pink to brownish discharge on a client who is 5 days postpartum
Almost colorless to creamy discharge on a client 2 weeks after delivery
A bright red discharge 5 days after delivery

Correct Answer

A. A bright red discharge 5 days after delivery

Explanation

Any bright red vaginal discharge would be considered abnormal, but especially 5 days after delivery, when the lochia is typically pink to brownish. Lochia rubra, a dark red discharge, is present for 2 to 3 days after delivery. Bright red vaginal bleeding at this time suggests late postpartum hemorrhage, which occurs after the first 24 hours following delivery and is generally caused by retained placental fragments or bleeding disorders. Option A: Lochia rubra is the normal dark red discharge occurring in the first 2 to 3 days after delivery, containing epithelial cells. erythrocyTes, leukocytes, and decidua. Option B: Lochia serosa is a pink to brownish serosanguineous discharge occurring from 3 to 10 days after delivery that contains decidua, erythrocytes, leukocytes, cervical mucus, and microorganisms. Option C: Lochia alba is an almost colorless to yellowish discharge occurring from 10 days to 3 weeks after delivery and contains leukocytes, decidua, epithelial cells, fat, cervical mucus, cholesterol crystals, and bacteria.

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3.

A postpartum client has a temperature of 101.4F, with a uterus that is tender when palpated, remains unusually large, and not descending as normally expected. Which of the following should the nurse assess next?

Lochia
Breasts
Incision
Urine

Correct Answer

A. Lochia

Explanation

The data suggests an infection of the endometrial lining of the uterus. The lochia may be decreased or copious, dark brown in appearance, and foul smelling, providing further evidence of a possible infection. Option B: All the client’s data indicate a uterine problem, not a breast problem. Typically, transient fever, usually 101F, may be present with breast engorgement. Symptoms of mastitis include influenza-like manifestations. Option C: Localized infection of an episiotomy or C-section incision rarely causes systemic symptoms, and uterine involution would not be affected. Option D: The client data do not include dysuria, frequency, urgency, or symptoms of urinary tract infections, which would necessitate assessing the client’s urine.

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4.

Which of the following should the nurse do when a primipara who is lactating tells the nurse that she has sore nipples?

Tell her to breastfeed more frequently
Administer a narcotic before breastfeeding
Encourage her to wear a nursing brassiere
Use soap and water to clean the nipples

Correct Answer

A. Tell her to breastfeed more frequently

Explanation

Feeding more frequently, about every 2 hours, will decrease the infant’s frantic, vigorous sucking from hunger and will decrease breast engorgement, soften the breast, and promote ease of correct latching on for feeding. Option B: Narcotics administered prior to breastfeeding are passed through the breast milk to the infant, causing excessive sleepiness. Nipple soreness is not severe enough to warrant narcotic analgesia. Option C: All postpartum clients, especially lactating mothers, should wear a supportive brassiere with wide cotton straps. This does not, however, prevent or reduce nipple soreness. Option D: Soaps are drying to the skin of the nipples and should not be used on the breasts of lactating mothers. Dry nipple skin predisposes to cracks and fissures, which can become sore and painful.

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5.

Which of the following would be the priority nursing diagnosis for a client with an ectopic pregnancy?

Risk for infection
Pain
Knowledge Deficit
Anticipatory Grieving

Correct Answer

A. Pain

Explanation

For the client with an ectopic pregnancy, lower abdominal pain, usually unilateral, is the primary symptom. Thus, pain is the priority. Option A: Although the potential for infection is always present, the risk is low in ectopic pregnancy because pathogenic microorganisms have not been introduced from external sources.Options C and D: The client may have limited knowledge of the pathology and treatment of the condition and will most likely experience grieving, but this is not the priority at this time.

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6.

Which of the following is the priority focus of nursing practice with the current early postpartum discharge?

Promoting comfort and restoration of health
Exploring the emotional status of the family
Facilitating safe and effective self and newborn care
Teaching about the importance of family planning

Correct Answer

A. Facilitating safe and effective self and newborn care

Explanation

Because of early postpartum discharge and limited time for teaching, the nurse’s priority is to facilitate the safe and effective care of the client and newborn. Options A. B. and D: Although promoting comfort and restoration of health, exploring the family’s emotional status. and teaching about family planning are important in postpartum/newborn nursing care. They are not the priority focus in the limited time presented by early postpartum discharge.

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7.

A client at 24 weeks gestation has gained 6 pounds in 4 weeks. Which of the following would be the priority when assessing the client?

Glucosuria
Depression
Hand/face edema
Dietary intake

Correct Answer

A. Hand/face edema

Explanation

After 20 weeks gestation, when there is a rapid weight gain, preeclampsia should be suspected, which may be caused by fluid retention manifested by edema, especially of the hands and face. The three classic signs of preeclampsia are hypertension, edema, and proteinuria. Option A: Although urine is checked for glucose at each clinic visit, this is not the priority. Option B: Depression may cause either anorexia or excessive food intake, leading to excessive weight gain or loss. This is not, however, the priority consideration at this time. Option D: Weight gain thought to be caused by excessive food intake would require a 24-hour diet recall. However, excessive intake would not be the primary consideration for this client at this time.

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8.

Which of the following actions would be least effective in maintaining a neutral thermal environment for the newborn?

Placing infant under radiant warmer after bathing
Covering the scale with a warmed blanket prior to weighing
Placing crib close to nursery window for family viewing
Covering the infant’s head with a knit stockinette

Correct Answer

A. Placing crib close to nursery window for family viewing

Explanation

Heat loss by radiation occurs when the infant’s crib is placed too near cold walls or windows. Thus placing the newborn’s crib close to the viewing window would be least effective. Body heat is lost through evaporation during bathing. Option A: Placing the infant under the radiant warmer after bathing will assist the infant in being rewarmed. Option B: Covering the scale with a warmed blanket prior to weighing prevents heat loss through conduction. Option D: A knit cap prevents heat loss from the head of a large head, a large body surface area of the newborn’s body.

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9.

A client 12 weeks pregnant come to the emergency department with abdominal cramping and moderate vaginal bleeding. Speculum examination reveals 2 to 3 cm cervical dilation. The nurse would document these findings as which of the following?

Threatened abortion
Imminent abortion
Complete abortion
Missed abortion

Correct Answer

A. Imminent abortion

Explanation

Cramping and vaginal bleeding coupled with cervical dilation signify that termination of the pregnancy is inevitable and cannot be prevented. Thus, the nurse would document an imminent abortion. Option A: In a threatened abortion, cramping and vaginal bleeding is present, but there is no cervical dilation. The symptoms may subside or progress to abortion. Option C: In a complete abortion, all the products of conception are expelled. Option D: A missed abortion is early fetal intrauterine death without expulsion of the products of conception.

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10.

The nurse assesses the vital signs of a client, 4 hours postpartum, which are as follows: BP 90/60; temperature 100.4 F; pulse 100 weak, thready; R 20 per minute. Which of the following should the nurse do first?

Report the temperature to the physician
Recheck the blood pressure with another cuff
Assess the uterus for firmness and position
Determine the amount of lochia

Correct Answer

A. Determine the amount of lochia

Explanation

A weak, thready pulse elevated to 100 BPM may indicate impending hemorrhagic shock. An increased pulse is a compensatory mechanism of the body in response to decreased fluid volume. Thus, the nurse should check the amount of lochia present. Option A: Temperatures up to 100.48F in the first 24 hours after birth are related to the dehydrating effects of labor and are considered normal. Option B: Although rechecking the blood pressure may be a correct choice of action, it is not the first action that should be implemented in light of the other data. The data indicate a potential impending hemorrhage. Option C: Assessing the uterus for firmness and position in relation to the umbilicus and midline is important, but the nurse should check the extent of vaginal bleeding first. Then it would be appropriate to check the uterus, which may be a possible cause of the hemorrhage.

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Practice With Maternal And Child Health Nursing NCLEX Test

Before assessing the postpartum client’s uterus for firmness and position in relation to the umbilicus and midline. Which of the following should the nurse do first?

Quiz Preview

The nurse assesses the postpartum vaginal discharge (lochia) on four clients. Which of the following assessments would warrant notification of the physician?

A postpartum client has a temperature of 101.4F, with a uterus that is tender when palpated, remains unusually large, and not descending as normally expected. Which of the following should the nurse assess next?

Which of the following should the nurse do when a primipara who is lactating tells the nurse that she has sore nipples?

Which of the following would be the priority nursing diagnosis for a client with an ectopic pregnancy?

Which of the following is the priority focus of nursing practice with the current early postpartum discharge?

A client at 24 weeks gestation has gained 6 pounds in 4 weeks. Which of the following would be the priority when assessing the client?

Which of the following actions would be least effective in maintaining a neutral thermal environment for the newborn?

A client 12 weeks pregnant come to the emergency department with abdominal cramping and moderate vaginal bleeding. Speculum examination reveals 2 to 3 cm cervical dilation. The nurse would document these findings as which of the following?

The nurse assesses the vital signs of a client, 4 hours postpartum, which are as follows: BP 90/60; temperature 100.4 F; pulse 100 weak, thready; R 20 per minute. Which of the following should the nurse do first?