Deck 25: Nursing Care of a Family Experiencing a Postpartum Complication

Question 1

A patient who gave birth 5 hours ago has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first?

A) Assess vital signs.
B) Assess the fundus.
C) Notify the health care provider.
D) Begin an IV infusion of Ringer's lactate solution.

Answer 1

Assess the fundus.

Question 2

The nurse is reviewing orders written for a postpartum patient with a fourth-degree perineal laceration. Which order should the nurse question before implementing?

A) Providing a sitz bath
B) Administering an enema
C) Urging to drink all the milk provided during meals
D) Administering acetaminophen and codeine for pain

Answer 2

Administering an enema

Question 3

The nurse is concerned that a postpartum patient with a cervical laceration is developing hypovolemic shock. What did the nurse assess in this patient?

A) Weak and rapid pulse
B) Warm and flushed skin
C) Elevated blood pressure
D) Decreased respiratory rate

Answer 3

Weak and rapid pulse

Question 4

The nurse is planning interventions to prevent the onset of urinary retention in a postpartum patient. Why are these interventions needed?

A) Frequent partial voiding never relieves the bladder pressure.
B) Catheterization at the time of delivery reduces bladder tonicity.
C) Mild dehydration causes a concentrated urine volume in the bladder.
D) Decreased bladder sensation results from edema because of pressure of birth.

Question 5

After delivery, a patient is diagnosed with postpartal gestational hypertension. What care will the nurse provide to this patient? (Select all that apply.)

A) Maintain on bed rest.
B) Monitor urine output.
C) Instruct on the purpose of a fluid restriction
D) Administer magnesium sulfate as prescribed.
E) Administer antihypertensive medication as prescribed.

Question 6

A postpartum patient is prescribed methylergonovine (Methergine) 0.2 mg for uterine subinvolution. Which action should the nurse take before administering the medication to the patient?

A) Assess ambulation.
B) Measure urine output.
C) Measure blood pressure.
D) Evaluate current hematocrit level.

Question 7

A patient is receiving treatment for a postpartum complication. Which action should the nurse perform to support the 2020 National Health Goals during the postpartum period?

A) Encourage to continue breastfeeding.
B) Suggest breastfeeding be discontinued.
C) Instruct on supplementing feedings with formula.
D) Explain how breastfeeding will weaken the patient's condition.

Question 8

The nurse is instructing a postpartum patient on observations to report to the health care provider which signifies retained placental fragments. Which patient statement indicates that teaching has been effective?

A) "If the drainage changes from clear to bright red, I am to call the doctor."
B) "I will have large amount of vaginal drainage for at least several months."
C) "An elevated temperature is normal during the first few weeks after delivery."
D) "My drainage will fluctuate between bright red and dark red for several weeks."

Question 9

A postpartum patient has a swollen area of purplish discoloration in the perineal area that is 5 cm in diameter. Which nursing diagnosis should the nurse use to plan care for this patient?

A) Acute pain
B) Risk for injury
C) Risk for infection
D) Ineffective peripheral tissue perfusion

Question 10

A postpartum patient is receiving antibiotics for endometritis. What should the nurse instruct the patient to observe in the infant with breastfeeding?

A) Jaundice
B) Irritability
C) Decreased sleep levels
D) White plaques in the mouth

Question 11

The nurse instructs a patient on actions to prevent postpartum depression. During a home visit, which observation indicates that instruction has been effective?

A) Patient complains of fatigue.
B) Patient appears disheveled and listless.
C) Patient is chatting on the telephone with a friend.
D) Patient is cleaning the kitchen while the baby naps.

Question 12

A postpartal patient is receiving heparin as treatment for thrombophlebitis. What should the nurse instruct the patient about breastfeeding during this time?

A) Breastfeeding can continue.
B) The baby will need weekly blood work.
C) The effect of anticoagulants is counteracted by infant gastric juices.
D) All anticoagulants pass in breast milk so breastfeeding will have to stop.

Question 13

A postpartal patient is being treated for a separated symphysis pubis. Which outcome should the nurse identify when planning care for this patient?

A) Patient plans to return to work in 2 weeks.
B) Patient has coordinated child care assistance.
C) Patient picks up the infant from the bassinette.
D) Patient has a urine output of 30 ml per hour or greater.

Question 14

A postpartum patient is diagnosed with a vaginal laceration. What intervention will the nurse provide to the patient at this time?

A) Monitor vital signs every 30 minutes.
B) Insert an indwelling urinary catheter.
C) Provide stool softeners as prescribed.
D) Weigh vaginal packing to estimate blood loss.

Question 15

During a home visit, a postpartum patient is complaining of a painful area on one breast. The nurse notes a local area on one breast to be red and warm to touch. For which health problem should the nurse plan care for this patient?

A) Mastitis
B) Breast cancer
C) Engorgement
D) Plugged milk duct