Postpartum and Newborn NCLEX

A postpartum client reports urinary frequency and burning. What cause would the nurse suspect?

• uterine atony

• urinary tract infection

• Subinvolution

• Stress Incontinence

A woman birth her infant 24 hours ago by cesarean. Which assessment findings should be reported to the assigned nurse? Select all that apply.

• Fundal height is one fingerbreadth below the umbilicus

• Bleeding is noted on the abdominal dressing

• Uterus is boggy

• New pain level of 7 out of 8.

• The client's abdomen is mildly distended and bowel sounds are hypoactive.

What findings should the nurse report to the health care provider for a postpartum client who delivered 12 hours ago? Select all that apply.

• Lochia Rubra

• Fundal height of one fingerbreadth above the umbilicus. (previously at the umbilicus)

• Episiotomy appears edematous.

• Temperature of 101.8

• WBC of 25,000

Answer explanation

The uterine fundus should be one fingerbreadth below, not above, the umbilicus. Maternal temperature does increase slightly after delivery but 38.8°C (101.8°F) is too high and the doctor needs to be made aware of it. All other findings are normal.

A postpartum mother calls the nurse in and tells her that her right calf hurts whenever she walks around the room or in the hall. What other data needs to be collected in assessing this client for a DVT? Select all that apply.

• Feel right calf for warmth

• Note any reddened areas on the right calf

• Measure the Diameter of both calves

• Have patient ambulate

• Have mother flex legs to assess for movement.

A postpartum client has a fourth-degree perineal laceration. The nurse would expect which medication to be prescribed?

• Ferrous Sulfate

• Methylergonovine

• docusate sodium

• bromocriptine

Answer explanation

A stool softener such as docusate may promote bowel elimination in a woman with a fourth-degree laceration, who may fear that bowel movements will be painful. Ferrous sulfate would be used to treat anemia. However, it is associated with constipation and would increase the discomfort when the woman has a bowel movement. Methylergonovine would be used to prevent or treat postpartum hemorrhage. Bromocriptine is used to treat hyperprolactinemia.

The nurse is teaching a postpartum woman and her spouse about postpartum blues. The nurse would instruct the couple to seek further care if the client's symptoms persist beyond which time frame?

• 1 week

• 2 weeks

• 3 weeks

• 4 weeks

Answer explanation

Symptoms worsening or persisting past two weeks need further evaluation for the potential of post partum depression (PPD).

New parents are upset their newborn has lost weight since birth. The nurse explains that newborns typically lose how much of their birth weight by 3 to 4 days of age?

• 10%

• 5%

• 15%

• 19%

A nurse is preparing to administer eye prophylaxis to a newborn. Which agent would the nurse most likely use?

• Vitamin K

• Hepatitis B Vaccine

• Erythromycin

• Clindamycin

The nursery head nurse is conducting a staff in-service on prevention of hypoglycemia. What information would she share with this group? Select all that apply.

• If a newborn becomes lethargic or sleepy, draw a heel stick blood glucose.

• Offer glucose feedings to all newborns at 1 hour of age.

• Encourage breastfeeding mothers to nurse immediately after delivery.

• Keep the newborns warm in the nursery and covered with a blanket.

• Initiate early feedings for all bottle-fed newborns.

A nurse is teaching new parents about keeping follow-up appointments and calling their health care provider if they notice signs of illness in their newborn. The nurse determines that the teaching was successful when the parents identify which signs as needing to be reported? Select all that apply.

• Temp of 101

• Cyanosis (circumoral)

• nighttime crying

• 6-8 wet diapers

• refusing feeding

Answer explanation

Any signs of infection, respiratory distress, or lack of sufficient intake would need to be reported.

6-8 diapers is adequate. Crying at Night is not indicative of an emergency or needs to be attended to.