Postpartum Nursing Quiz

The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss?

• A temperature of 100.4° F (38° C)

• An increase in the pulse rate from 88 to 102 beats per minute

• A blood pressure change from 130/88 to 124/80 mm Hg

• An increase in the respiratory rate from 18 to 22 breaths per minute

The nurse is collaborating with the RN to prepare a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions would be included on the list? Select all that apply.

• Take the prescribed antibiotics until the soreness subsides.

• Maintain a fluid intake of at least 3000 mL/day.

• Continue to breast-feed/chest-feed if the breasts are not too sore.

• Rest during the acute phase.

• Wear a supportive bra.

The nurse is collaborating with the RN to provide instructions about measures to prevent postpartum mastitis to a client who is breast-feeding/chest-feeding the newborn. Which client statement would indicate a need for further instruction?

• I need to breast-feed every 2 to 3 hours.

• I need to change the breast pads frequently.

• I need to wash my hands well before breast-feeding.

• I need to wash my nipples daily with soap and water.

The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign would the nurse note if superficial venous thrombosis were present?

• Paleness of the calf area

• Coolness of the calf area

• Enlarged, hardened veins

• Palpable dorsalis pedis pulses

A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which would be the initial nursing action?

• Initiate an intravenous line

• Assess the client’s blood pressure

• Prepare to administer morphine sulfate

• Administer oxygen, 8 to 10 L/minute, by face mask

The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm but that bleeding is excessive. Which would be the initial nursing action?

• Record the findings

• Massage the fundus

• Notify the obstetrician (OB)

• Place the client in Trendelenburg’s position

The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage?

• A primiparous client who delivered 4 hours ago

• A multiparous client who delivered 6 hours ago

• A multiparous client who delivered a large baby after oxytocin induction

• A primiparous client who delivered 6 hours ago and had epidural anesthesia

A postpartum client is diagnosed with cystitis. The nurse would plan for which priority action in the care of the client?

• Providing sitz baths

• Encouraging fluid intake

• Placing ice on the perineum

• Monitoring hemoglobin and hematocrit levels

The nurse is monitoring a postpartum client who delivered 1 hour ago and received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma?

• Changes in vital signs

• Signs of heavy bruising

• Complaints of intense pain

• Complaints of a tearing sensation

The nurse is assisting with creating a plan of care for a postpartum client with a small vulvar hematoma. The nurse would include which specific action during the first 12 hours after delivery?

• Encourage ambulation hourly.

• Assess vital signs every 4 hours.

• Measure fundal height every 4 hours.

• Prepare an ice pack for application to the area.