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Terms in this set (16)
The nurse who is employed in a prenatal clinic is performing prenatal assessments on clients who are in their first trimester of pregnancy. The nurse is concerned with identifying clients who may be at risk for the development of postpartum complications. Which clients would be at most risk for development of postpartum thromboembolic disorders? Select all that apply.
1. A 39-year-old woman who reports that she smokes
4. A 37-year-old woman in her fourth pregnancy who is overweight
5. A 22-year-old woman in a first pregnancy who states that oral contraceptives taken in the past have caused thrombophlebitis
The nurse has provided instructions for a postpartum client at risk for thrombosis regarding measures to prevent its occurrence. Which statement, if made by the client, indicates a need for further education?
1. "I should apply my antiembolism stockings after breakfast."
The discharge nurse is discussing mastitis with a postpartum client. Which statement made by the client indicates a need for further instruction?
3. "If I develop a fever, chills, or body aches at any time after discharge, I should stop breast-feeding immediately."
On assessment of a client who is 30 minutes into the fourth stage of labor, the nurse finds the client's perineal pad saturated with blood and blood soaked into the bed linen under the client's buttocks. Which is the nurse's initial action
3. Gently massage the uterine fundus.
After receiving report at the beginning of the 0700 shift, the nurse must decide in what order the clients should be assessed. How should the nurse plan assessments? Arrange the clients in the order that they should be assessed. All options must be used.
1. A 12-hour post-cesarean section delivery gravida 3, para 3 who reports a return of feeling in her lower extremities as well as a sensation of wetness underneath her buttocks.
2. A 24-hour post-vaginal delivery gravida 4, para 4 who is complaining of abdominal cramping after nursing her baby and requesting ibuprofen.
3. An 8-hour post-vaginal delivery gravida 2, para 2 client who is scheduled for a bilateral tubal ligation at 1200 today and has a continuous peripheral intravenous (IV)
4. 48-hour post-cesarean section delivery gravida 1, para 1 who reports not yet having a bowel movement since delivery and requests a stool softener.
A client who is a gravida 3, para 3 had a cesarean section 1 day ago. She is being treated prophylactically for endometritis. She is complaining of abdominal cramping at a 6 on a pain level scale of 1 to 10 (with 10 being the greatest amount of pain) and fears having her first bowel movement. These medications are prescribed and due now. Based on priority, in which order should the nurse administer the medications? Arrange the medications in the order that they should be administered. All options must be used.
1. Ketorolac 30 mg by intravenous (IV) push over 3 minutes
2. Ampicillin sodium 1 g IV piggyback over 60 minutes
3. Docusate sodium 100 mg orally daily
4.Prenatal vitamin 1 tablet orally daily
The nurse is checking lochia discharge in a woman in the immediate postpartum period. The nurse notes that the lochia is bright red and contains some small clots. Based on these data, the nurse should make which interpretation?
3. The client is experiencing normal lochia discharge.
A postpartum woman with mastitis in the right breast complains that the breast is too sore for her to breast-feed her infant. The nurse should tell the client to implement which measure?
3. Breast-feed from the left breast and gently pump the right breast.
The rubella vaccine has been prescribed for a new mother. Which statements should the postpartum nurse make when providing information about the vaccine to the client? Select all that apply.
2. "You need this vaccine because you are not immune to the rubella virus."
4. "You should not become pregnant for 1 to 3 months after the administration of the vaccine."
The nurse has just received an intershift report. After reviewing the client assignment and the appropriate medical records, the nurse determines that which client is most at risk for developing postdelivery endometritis?
4. An adolescent experiencing an emergency cesarean delivery for fetal distress
The nurse provides a list of discharge instructions to a client who has delivered a healthy newborn by cesarean delivery. Which statement by the client indicates the need for further teaching?
1. "A fever on and off is expected and is nothing to worry about."
The nurse is caring for a client who has just delivered a newborn following a pregnancy with placenta previa. When reviewing the plan of care, the nurse should prepare to monitor the client for which risk that is associated with placenta previa?
The nurse is preparing to perform a fundal assessment on a postpartum client. The nurse understands that which is the initial nursing action when performing this assessment?
2. Ask the client to urinate and empty her bladder.
4. 15 minutes during the first hour and then every 30 minutes for the next 2 hours
The nurse is providing nutritional counseling to a new mother who is breast-feeding her newborn. The nurse should instruct the client that her calorie needs should increase by approximately how many calories a day?
Which additional daily dietary intake will most closely match the number of additional calories needed by the breast-feeding mother?
2. Peanut butter and jelly sandwich and glass of 2% milk
THIS SET IS OFTEN IN FOLDERS WITH...
Maternity - Intrapartum NCLEX question Exam 2
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