NCLEX - MATERNITY Day2 (Part 2)

What nursing advice relieves breast engorgement for non-breastfeeding postpartum client?

• Apply heat frequently to both breasts
• Manually express milk several times a day
• Massage breasts from the base to the nipple 3 or 4 times a day
• Use chilled, fresh cabbage leaves on breasts throughout the day
• -

Answer explanation

Cabbage leaves reduce engorgement naturally without stimulating milk production, which should be avoided in non-breastfeeding clients.

Which postpartum findings 12 hours after vaginal delivery need follow-up?

• Foul-smelling lochia
• Temperature of 100°F (37.8°C)
• A painful external hemorrhoid
• Discomfort during fundal massage
• -

Answer explanation

Foul-smelling lochia suggests infection and must be reported promptly.

Which behavior suggests postpartum psychosis?

• Tearfulness and feeling overwhelmed at day 3
• Worry and hypervigilance at 6 months
• Depression and insomnia at 2 months
• Disorganized behavior and delusions at day 5
• -

Answer explanation

Postpartum psychosis presents within 2 weeks with manic behavior, insomnia, and psychotic features; it’s a psychiatric emergency.

Which first-trimester client requires priority teaching?

• Gardens and eats homegrown vegetables
• Has gained 4 lb since prepregnancy
• Reports thin white vaginal discharge
• Swims and practices yoga
• -

Answer explanation

Gardening and eating unwashed produce increase risk for toxoplasmosis, which is teratogenic. Proper washing precautions are needed.

Which postpartum statement on day 5 warrants concern?

• Tired all the time
• Bright red blood in bowel movement
• Bleeding like a heavy period with clots
• Hands feel tingly when holding baby
• -

Answer explanation

Heavy bleeding with clots after lochia should have decreased suggests secondary postpartum hemorrhage and needs follow-up.

Which action is priority for client 2 hrs post vaginal delivery who soaked pad in 20 mins and has boggy, right-deviated fundus?

• Assist client to void using bedpan
• Administer IV oxytocin
• Obtain CBC
• Administer oxygen via nonrebreather
• -

Answer explanation

Bladder distension displaces the uterus and contributes to bleeding; helping the client void is the first step to control hemorrhage.

Which order should the nurse clarify for a client with boggy fundus and elevated BP?

• Insert urinary catheter
• Administer methylergonovine IM
• Insert second IV line
• Check hemoglobin and hematocrit
• -

Answer explanation

Methylergonovine is contraindicated in hypertension due to vasoconstrictive effects; clarification is required.

Which education should be provided for preeclampsia without severe features?

• Perform fetal kick counts daily
• Limit fluid intake to 1 L
• Monitor blood pressure
• Report vaginal bleeding
• Report headaches and vision changes

Answer explanation

Fetal monitoring, BP checks, and reporting signs of worsening disease are essential; fluid restriction is not recommended unless indicated.