Take The NCLEX Quiz On Obstetrical Nursing

1. A postpartum nurse is preparing to care for a woman who has just delivered a healthy newborn infant. In the immediate postpartum period the nurse plans to take the woman's vital signs:

Every 30 minutes during the first hour and then every hour for the next two hours.

Every 15 minutes during the first hour and then every 30 minutes for the next two hours.

Every hour for the first 2 hours and then every 4 hours

Every 5 minutes for the first 30 minutes and then every hour for the next 4 hours

The correct answer is to take the woman's vital signs every 15 minutes during the first hour and then every 30 minutes for the next two hours. This frequency of monitoring allows the nurse to closely monitor the woman's vital signs during the immediate postpartum period when there is a higher risk of complications such as hemorrhage or infection. The more frequent monitoring during the first hour ensures that any immediate changes in vital signs can be quickly identified and addressed. As the woman's condition stabilizes, the frequency of monitoring can be decreased to every 30 minutes for the next two hours, as it is still important to monitor for any delayed complications.

Explanation

The correct answer is to take the woman's vital signs every 15 minutes during the first hour and then every 30 minutes for the next two hours. This frequency of monitoring allows the nurse to closely monitor the woman's vital signs during the immediate postpartum period when there is a higher risk of complications such as hemorrhage or infection. The more frequent monitoring during the first hour ensures that any immediate changes in vital signs can be quickly identified and addressed. As the woman's condition stabilizes, the frequency of monitoring can be decreased to every 30 minutes for the next two hours, as it is still important to monitor for any delayed complications.

2. The nurse is assessing the lochia on a 1 day PP patient. The nurse notes that the lochia is red and has a foul-smelling odor. The nurse determines that this assessment finding is:

Normal

Indicates the presence of infection

Indicates the need for increasing oral fluids

Indicates the need for increasing ambulation

Lochia. the discharge present after birth. is red for the first 1 to 3 days and gradually decreases in amount. Foul smelling or purulent lochia usually indicates infection. and these findings are not normal.Option A: Normal lochia has a fleshy odor.Options C and D: Encouraging the woman to drink fluids or increase ambulation is not an accurate nursing intervention.

Explanation

Lochia. the discharge present after birth. is red for the first 1 to 3 days and gradually decreases in amount. Foul smelling or purulent lochia usually indicates infection. and these findings are not normal.Option A: Normal lochia has a fleshy odor.Options C and D: Encouraging the woman to drink fluids or increase ambulation is not an accurate nursing intervention.

3. A nurse is preparing to perform a fundal assessment on a postpartum client. The initial nursing action in performing this assessment is which of the following?

Ask the client to turn on her side

Ask the client to lie flat on her back with the knees and legs flat and straight.

Ask the mother to urinate and empty her bladder

Massage the fundus gently before determining the level of the fundus

Before starting the fundal assessment. the nurse should ask the mother to empty her bladder so that an accurate assessment can be done.Options A and B: When the nurse is performing a fundal assessment. the nurse asks the woman to lie flat on her back with the knees flexed.Option D: Massaging the fundus is not appropriate unless the fundus is boggy and soft. and then it should be massaged gently until firm.

Explanation

Before starting the fundal assessment. the nurse should ask the mother to empty her bladder so that an accurate assessment can be done.Options A and B: When the nurse is performing a fundal assessment. the nurse asks the woman to lie flat on her back with the knees flexed.Option D: Massaging the fundus is not appropriate unless the fundus is boggy and soft. and then it should be massaged gently until firm.

4. A PP nurse is providing instructions to a woman after delivery of a healthy newborn infant. The nurse instructs the mother that she should expect normal bowel elimination to return:

One the day of the delivery

3 days PP

7 days PP

Within 2 weeks PP

After birth. the nurse should auscultate the woman’s abdomen in all four quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days PP. Surgery. anesthesia. and the use of narcotics and pain control agents also contribute to the longer period of altered bowel function.

Explanation

After birth. the nurse should auscultate the woman’s abdomen in all four quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days PP. Surgery. anesthesia. and the use of narcotics and pain control agents also contribute to the longer period of altered bowel function.

5. When performing a PP assessment on a client. the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which of the following nursing actions is most appropriate?

Document the findings

Notify the physician

Reassess the client in 2 hours

Encourage increased intake of fluids

Normally. one may find a few small clots in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots. such as uterine atony or retained placental fragments. needs to be determined and treated to prevent further blood loss. Although the findings would be documented. the most appropriate action is to notify the physician.

Explanation

Normally. one may find a few small clots in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots. such as uterine atony or retained placental fragments. needs to be determined and treated to prevent further blood loss. Although the findings would be documented. the most appropriate action is to notify the physician.

6. Upon completion of a vaginal examination on a laboring woman. the nurse records 50%. 6 cm. -1. Which of the following is a correct interpretation of the data?

Fetal presenting part is 1 cm above the ischial spines

Effacement is 4 cm from completion

Dilation is 50% completed

Fetus has achieved passage through the ischial spines

Station of – 1 indicates that the fetal presenting part is above the ischial spines and has not yet passed through the pelvic inlet. A station of zero would indicate that the presenting part has passed through the inlet and is at the level of the ischial spines or is engaged.Options B and C: Progress of effacement is referred to by percentages with 100% indicating full effacement and dilation by centimeters (cm) with 10 cm indicating full dilation.Option D: Passage through the ischial spines with internal rotation would be indicated by a plus station. such as + 1.

Explanation

Station of – 1 indicates that the fetal presenting part is above the ischial spines and has not yet passed through the pelvic inlet. A station of zero would indicate that the presenting part has passed through the inlet and is at the level of the ischial spines or is engaged.Options B and C: Progress of effacement is referred to by percentages with 100% indicating full effacement and dilation by centimeters (cm) with 10 cm indicating full dilation.Option D: Passage through the ischial spines with internal rotation would be indicated by a plus station. such as + 1.

7. A nurse in a PP unit is instructing a mother regarding lochia and the amount of expected lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never exceed the need for:

One peripad per day

Two peripads per day

Three peripads per day

Eight peripads per day

The normal amount of lochia may vary with the individual but should never exceed 4 to 8 peripads per day. The average number of peripads is 6 per day.

Explanation

The normal amount of lochia may vary with the individual but should never exceed 4 to 8 peripads per day. The average number of peripads is 6 per day.

8. Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of Pitocin. The woman is in a side-lying position. and her vital signs are stable and fall within a normal range. Contractions are intense. last 90 seconds. and occur every 1 1/2 to 2 minutes. The nurse’s immediate action would be to:

Change the woman’s position

Stop the Pitocin

Elevate the woman’s legs

Administer oxygen via a tight mask at 8 to 10 liters/minute

Late deceleration patterns noted are most likely related to alteration in uteroplacental perfusion associated with the strong contractions described. The immediate action would be to stop the Pitocin infusion since Pitocin is an oxytocin which stimulates the uterus to contract.Option A: The woman is already in an appropriate position for uteroplacental perfusion.Option C: Elevation of her legs would be appropriate if hypotension were present.Option D: Oxygen is appropriate but not the immediate action.

Explanation

Late deceleration patterns noted are most likely related to alteration in uteroplacental perfusion associated with the strong contractions described. The immediate action would be to stop the Pitocin infusion since Pitocin is an oxytocin which stimulates the uterus to contract.Option A: The woman is already in an appropriate position for uteroplacental perfusion.Option C: Elevation of her legs would be appropriate if hypotension were present.Option D: Oxygen is appropriate but not the immediate action.

9. The nurse should realize that the most common and potentially harmful maternal complication of epidural anesthesia would be:

Severe postpartum headache

Limited perception of bladder fullness

Increase in respiratory rate

Hypotension

Epidural anesthesia can lead to vasodilation and a drop in blood pressure that could interfere with adequate placental perfusion. The woman must be well hydrated before and during epidural anesthesia to prevent this problem and maintain an adequate blood pressure.Option A: Headache is not a side effect since the spinal fluid is not disturbed by this anesthetic as it would be with a low spinal (saddle block) anesthesia.Option B is an effect of epidural anesthesia but is not the most harmful.Option C: Respiratory depression is a potentially serious complication.

Explanation

Epidural anesthesia can lead to vasodilation and a drop in blood pressure that could interfere with adequate placental perfusion. The woman must be well hydrated before and during epidural anesthesia to prevent this problem and maintain an adequate blood pressure.Option A: Headache is not a side effect since the spinal fluid is not disturbed by this anesthetic as it would be with a low spinal (saddle block) anesthesia.Option B is an effect of epidural anesthesia but is not the most harmful.Option C: Respiratory depression is a potentially serious complication.

10. A client is admitted to the L & D suite at 36 weeks’ gestation. She has a history of C-section and complains of severe abdominal pain that started less than 1 hour earlier. When the nurse palpates tetanic contractions. the client again complains of severe pain. After the client vomits. she states that the pain is better and then passes out. Which is the probable cause of her signs and symptoms?

Hysteria compounded by the flu

Placental abruption

Uterine rupture

Dysfunctional labor

Uterine rupture is a medical emergency that may occur before or during labor. Signs and symptoms typically include abdominal pain that may ease after uterine rupture. vomiting. vaginal bleeding. hypovolemic shock. and fetal distress. With placental abruption. the client typically complains of vaginal bleeding and constant abdominal pain.

Explanation

Uterine rupture is a medical emergency that may occur before or during labor. Signs and symptoms typically include abdominal pain that may ease after uterine rupture. vomiting. vaginal bleeding. hypovolemic shock. and fetal distress. With placental abruption. the client typically complains of vaginal bleeding and constant abdominal pain.

11. The nurse is assessing a client who is 6 hours PP after delivering a full-term healthy infant. The client complains to the nurse of feelings of faintness and dizziness. Which of the following nursing actions would be most appropriate?

Obtain hemoglobin and hematocrit levels

Instruct the mother to request help when getting out of bed

Elevate the mother’s legs

Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that should caution the nurse to be aware of the client’s safety. The nurse should advise the mother to get help the first few times the mother gets out of bed.Option A: Obtaining an H/H requires a physician’s order.

Explanation

Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that should caution the nurse to be aware of the client’s safety. The nurse should advise the mother to get help the first few times the mother gets out of bed.Option A: Obtaining an H/H requires a physician’s order.

12. Perineal care is an important infection control measure. When evaluating a postpartum woman’s perineal care technique. the nurse would recognize the need for further instruction if the woman:

Uses soap and warm water to wash the vulva and perineum

Washes from symphysis pubis back to episiotomy

Changes her perineal pad every 2 – 3 hours

Uses the peri bottle to rinse upward into her vagina

The peri bottle should be used in a backward direction over the perineum. The flow should never be directed upward into the vagina since debris would be forced upward into the uterus through the still-open cervix.

Explanation

The peri bottle should be used in a backward direction over the perineum. The flow should never be directed upward into the vagina since debris would be forced upward into the uterus through the still-open cervix.

13. A postpartum nurse is taking the vital signs of a woman who delivered a healthy newborn infant 4 hours ago. The nurse notes that the mother's temperature is 100.2*F. Which of the following actions would be most appropriate?

Retake the temperature in 15 minutes

Notify the physician

Document the findings

Increase hydration by encouraging oral fluids

The mother’s temperature may be taken every 4 hours while she is awake. Temperatures up to 100.4 F (38 C) in the first 24 hours after birth are often related to the dehydrating effects of labor. The most appropriate action is to increase hydration by encouraging oral fluids. which should bring the temperature to a normal reading.Option C: Although the nurse would document the findings. the most appropriate action would be to increase the hydration.

Explanation

The mother’s temperature may be taken every 4 hours while she is awake. Temperatures up to 100.4 F (38 C) in the first 24 hours after birth are often related to the dehydrating effects of labor. The most appropriate action is to increase hydration by encouraging oral fluids. which should bring the temperature to a normal reading.Option C: Although the nurse would document the findings. the most appropriate action would be to increase the hydration.

14. Parents can facilitate the adjustment of their other children to a new baby by:

Having the children choose or make a gift to give to the new baby upon its arrival home

Emphasizing activities that keep the new baby and other children together

Having the mother carry the new baby into the home so she can show the other children the new baby

Reducing stress on other the by limiting their involvement in the care of the new baby

Special time should be set aside just for the other children without interruption from the newborn. Someone other than the mother should carry the baby into the home so she can give full attention to greeting her other children. Children should be actively involved in the care of the baby according to their ability without overwhelming them.

Explanation

Special time should be set aside just for the other children without interruption from the newborn. Someone other than the mother should carry the baby into the home so she can give full attention to greeting her other children. Children should be actively involved in the care of the baby according to their ability without overwhelming them.

15. A nurse is caring for a PP woman who has received epidural anesthesia and is monitoring the woman for the presence of a vulva hematoma. Which of the following assessment findings would best indicate the presence of a hematoma?

Complaints of a tearing sensation

Complaints of intense pain

Changes in vital signs

Signs of heavy bruising

Changes in vitals indicate hypovolemia in the anesthetized PP woman with vulvar hematoma.Options A and B: Because the woman has had epidural anesthesia and is anesthetized. she cannot feel pain. pressure. or a tearing sensation.Option D: Heavy bruising may be visualized. but vital sign changes indicate hematoma caused by blood collection in the perineal tissues.

Explanation

Changes in vitals indicate hypovolemia in the anesthetized PP woman with vulvar hematoma.Options A and B: Because the woman has had epidural anesthesia and is anesthetized. she cannot feel pain. pressure. or a tearing sensation.Option D: Heavy bruising may be visualized. but vital sign changes indicate hematoma caused by blood collection in the perineal tissues.

16. Select all of the physiological maternal changes that occur during the PP period.

Cervical involution occurs

Vaginal distention decreases slowly

Fundus begins to descend into the pelvis after 24 hours

Cardiac output decreases with resultant tachycardia in the first 24 hours

Digestive processes slow immediately

After 1 week the muscle begins to regenerate and the cervix feels firm and the external os. is the width of a pencil. The fundus begins to descent into the pelvic cavity after 24 hours. a process known as involution.Option B: Although the vaginal mucosa heals and vaginal distention decreases. it takes the entire PP period for complete involution to occur and muscle tone is never restored to the pregravid state.Option D: Despite blood loss that occurs during delivery of the baby. a transient increase in cardiac output occurs. The increase in cardiac output. which persists about 48 hours after childbirth. is probably caused by an increase in stroke volume because Bradycardia is often noted during the PP period.Option E: Soon after childbirth. digestion begins to begin to be active. and the new mother is usually hungry because of the energy expended during labor.

Explanation

After 1 week the muscle begins to regenerate and the cervix feels firm and the external os. is the width of a pencil. The fundus begins to descent into the pelvic cavity after 24 hours. a process known as involution.Option B: Although the vaginal mucosa heals and vaginal distention decreases. it takes the entire PP period for complete involution to occur and muscle tone is never restored to the pregravid state.Option D: Despite blood loss that occurs during delivery of the baby. a transient increase in cardiac output occurs. The increase in cardiac output. which persists about 48 hours after childbirth. is probably caused by an increase in stroke volume because Bradycardia is often noted during the PP period.Option E: Soon after childbirth. digestion begins to begin to be active. and the new mother is usually hungry because of the energy expended during labor.

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