Derek Moore
Test por , creado hace más de 1 año

I do not take credit for these questions. They are from the book. Ch 30-32

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Derek Moore
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OB-Postpartum NCLEX Questions

Pregunta 1 de 42

1

The nurse had completed a postpartum assessment on a patient who gave birth to her first child 12 hours ago. She
is nauseated, but has not vomited in the last 2 hours. Her fundus was boggy, and firmed with massage to 1 FB ↓ U,
moderately heavy lochia rubra, perineum ecchymotic and edematous, and pain rating 6 on scale of 1–10. Her
partner is present and supportive. Breastfeeding has been successful three times. Which nursing diagnosis has the
highest priority for this patient?

Selecciona una de las siguientes respuestas posibles:

  • Acute pain related to perineal trauma

  • Risk for deficient fluid volume related to uterine bleeding and nausea

  • Readiness for enhanced family coping

  • Knowledge deficit related to newborn care

Explicación

Pregunta 2 de 42

1

During a home care visit, the new mother complains of breast engorgement. Which intervention is most
appropriate for recommendation by the home care nurse?

Selecciona una de las siguientes respuestas posibles:

  • “Apply an ice compress to your breast before nursing.”

  • “Encourage your baby to suckle for an average of 5 minutes per feeding.”

  • “Apply warm compresses to your breast after you finish feeding your baby.”

  • “When you aren’t nursing, wear a well-fitted nursing bra at all times, even when you sleep.”

Explicación

Pregunta 3 de 42

1

The postpartum patient delivered 4 hours ago. She has a mediolateral episiotomy and large hemorrhoids. She is
rating her pain at 7 on a scale of 1–10. She has a history of anaphylactic reaction to Tylenol (acetaminophen).
Which nursing action would be best?

Selecciona una de las siguientes respuestas posibles:

  • Offer the patient 800 mg Advil (ibuprofen) orally with food.

  • Provide two Percocet (oxycodone with acetaminophen) by mouth.

  • Encourage use of Dermoplast topical anesthetic spray.

  • Run very warm water into the tub and assist her into the bath.

Explicación

Pregunta 4 de 42

1

On the second day postpartum, the patient experiences engorgement. To relieve her discomfort, the nurse should encourage the patient to:

Selecciona una de las siguientes respuestas posibles:

  • Remove her bra.

  • Apply heat to her breasts.

  • Apply ice packs to her breasts.

  • Limit breastfeeding to twice daily.

Explicación

Pregunta 5 de 42

1

The nurse is caring for a patient who had a cesarean birth 4 hours ago. Which of the following interventions would the nurse implement at this time?

Selecciona una o más de las siguientes respuestas posibles:

  • Administer analgesics as needed.

  • Encourage the patient to ambulate to the bathroom to void.

  • Encourage leg exercises every 2 hours.

  • Encourage the patient to cough and deep-breathe every 2–4 hours.

  • Encourage the use of breathing, relaxation, and distraction.

Explicación

Pregunta 6 de 42

1

The community health nurse is presenting a seminar to new mothers about breastfeeding. When discussing weaning, which new mother’s statement suggests a need for further teaching?

Selecciona una de las siguientes respuestas posibles:

  • “Slow weaning should take place over a period of several months.”

  • “By weaning my baby slowly, I’m giving him time to change his eating method at his own pace.”

  • “If I wean my baby slowly, I am less likely to develop breast engorgement.”

  • “Slowly weaning my baby is recommended to allow time for psychological adjustment.”

Explicación

Pregunta 7 de 42

1

The hospital is developing a new maternity unit. What aspects should be included in the planning of this new unit to best promote family wellness?

Selecciona una de las siguientes respuestas posibles:

  • Normal newborn nursery centrally located to all patient rooms

  • A kitchen with refrigerator stocked with juice and sandwiches

  • Small, cozy rooms with a patient bed and rocking chair

  • A nursing model based on providing couplet care

Explicación

Pregunta 8 de 42

1

The patient having her second child is scheduled for a cesarean birth because the baby is in a breech presentation. The patient states, “I’m wondering what will be different this time compared with my first birth, which was vaginal.” What response is best?

Selecciona una de las siguientes respuestas posibles:

  • “We’ll take good care of you and your baby. You’ll be home before you know it.”

  • “You’ll be wearing long stockings to prevent blood clots from forming in your legs.”

  • “You will have a lot of pain, but there are medications that we give when it gets bad.”

  • “You won’t be able to nurse until the baby is 12 hours old, because of your epidural.”

Explicación

Pregunta 9 de 42

1

The nurse is caring for a patient who delivered by cesarean birth. The patient received a general anesthetic. The nurse would encourage which of the following in order to prevent or minimize abdominal distention?

Selecciona una o más de las siguientes respuestas posibles:

  • Increased intake of cold beverages

  • Leg exercises every 2 hours

  • Abdominal tightening

  • Ambulation

  • Eating a high-protein general diet

Explicación

Pregunta 10 de 42

1

The nurse is caring for a 15-year-old patient that gave birth to her first child yesterday. What action is the best indicator that the nurse understands the parenting adolescent?

Selecciona una de las siguientes respuestas posibles:

  • The patient’s mother is included in all discussions and demonstrations.

  • The father of the baby is encouraged to change a diaper and give a bottle.

  • The nurse explains the characteristics and cues of the baby during the assessment.

  • A discussion on contraceptive methods is the first topic of teaching.

Explicación

Pregunta 11 de 42

1

The nurse is preparing to receive a newly delivered patient. The patient is a young single mother who is relinquishing custody of her newborn through an open adoption. What action is most important?

Selecciona una de las siguientes respuestas posibles:

  • Assign the patient a room on the GYN surgical floor instead of the postpartum floor.

  • Prepare to have teaching done in time for discharging the patient at 24 hours postdelivery.

  • Make an effort to not bring up the topic of the baby, and discuss the mother’s health instead.

  • Ask the patient if she wants to feed her baby, and how much contact she wants to have.

Explicación

Pregunta 12 de 42

1

The nurse is caring for a patient who plans to relinquish her baby for adoption. The nurse would implement which of the following approaches to care?

Selecciona una o más de las siguientes respuestas posibles:

  • Encourage the patient to see and hold her infant.

  • Encourage the patient to express her emotions.

  • Respect any special requests for the birth.

  • Acknowledge the grieving process in the patient.

  • Allow for access to the infant if the patient requests it.

Explicación

Pregunta 13 de 42

1

The maternal home care nurse is orienting a new nurse. During orientation, they are discussing maternal psychological adaptations and stressors. Which statement by the maternal home care nurse reflects the correct approach to addressing potential and actual postpartum depression in maternal patients?

Selecciona una de las siguientes respuestas posibles:

  • “Because emotional disorders and imbalances are a very sensitive subject, we try not to offend patients by routinely bringing up the topic of postpartum depression.”

  • “For women with a history of depression, we include education about postpartum depression.”

  • “Teaching about postpartum depression is a routine part of education for all maternal patients.”

  • “If we suspect a woman may have developed postpartum depression, then we provide specialized education about that topic.”

Explicación

Pregunta 14 de 42

1

During a home care visit, a couple expresses a desire for cosleeping, or sleeping in the same bed with their newborn baby. Which nursing response is most appropriate?

Selecciona una de las siguientes respuestas posibles:

  • “Current research suggests there are no physical risks related to cosleeping, and this recommended as a healthy psychological approach to family bonding.

  • “Cosleeping is a safe and healthy practice, as long as you make sure your baby is sleeping on his stomach.”

  • “Cosleeping is considered a risk factor for SIDS, so families who practice cosleeping need to following specific safety guidelines.”

  • “If you practice cosleeping, your baby should be placed on a comforter, as opposed to directly on the mattress.”

Explicación

Pregunta 15 de 42

1

The nurse has received an end of shift report on the postpartum unit. Which patient should she see first?

Selecciona una de las siguientes respuestas posibles:

  • Multip, second day post-cesarean, moderate lochia serosa

  • Primip, day of delivery, fundus firm 2 cm above umbilicus

  • Multip, first postpartum day, 4 cm diastasis recti abdominis

  • Primip, first postpartum day, hypoactive bowel sounds all quadrants

Explicación

Pregunta 16 de 42

1

The nurse expects an initial weight loss for the average postpartum patient to be:

Selecciona una de las siguientes respuestas posibles:

  • 5-8 lbs

  • 10-12 lbs

  • 12-15 lbs

  • 15-20 lbs

Explicación

Pregunta 17 de 42

1

To assess healing of the uterus at the placental site, the nurse assesses:

Selecciona una de las siguientes respuestas posibles:

  • Lab values

  • Blood Pressure

  • Uterine Size

  • Type, amount, and consistency of lochia

Explicación

Pregunta 18 de 42

1

A Jewish patient delivers a healthy baby boy on Thursday afternoon, and she is set to be discharged on Saturday morning. Why might this present a problem for the patient?

Selecciona una de las siguientes respuestas posibles:

  • Jewish custom is to have the infant circumcised two days after birth.

  • The woman will expect to be in the hospital at least seven days after delivery.

  • Saturday is considered the Sabbath and she will not be able to leave the hospital that day.

  • The husband cannot touch his wife while she is experiencing vaginal discharge, so he will not be able to assist his wife to and from the vehicle.

Explicación

Pregunta 19 de 42

1

On the first postpartum day, the nurse teaches the patient about breastfeeding. Two hours later, the mother seems to remember very little of the teaching. The nurse understands this memory lapse to be due to:

Selecciona una de las siguientes respuestas posibles:

  • The taking-hold phase.

  • PPH

  • The taking-in phase

  • Epidural anesthesia

Explicación

Pregunta 20 de 42

1

The nurse is working with a new mother who follows Muslim traditions. Which expectations and actions are appropriate for this patient?

Selecciona una o más de las siguientes respuestas posibles:

  • Be sure she gets a kosher diet.

  • Expect that most visitors will be women.

  • Uncover only the necessary skin when assessing.

  • The patient will avoid cold air and water after birth.

  • She will prefer a male physician

Explicación

Pregunta 21 de 42

1

The nurse is observing a new graduate’s assessment of a postpartum patient. Which action by the student nurse should prompt a corrective intervention by the preceptor nurse?

Selecciona una de las siguientes respuestas posibles:

  • Ask the patient to void, and don clean gloves.

  • Discussing the effectiveness of patient comfort measures while performing the perineal assessment.

  • Instructing the patient’s visitors to leave the room prior to beginning the assessment.

  • Requesting that the patient lie flat in bed with her head on a pillow prior to the fundal assessment

Explicación

Pregunta 22 de 42

1

The nurse is performing a postpartum assessment on a newly delivered patient. When checking the fundus, there is a gush of blood. The patient asks why that is happening. The best response is:

Selecciona una de las siguientes respuestas posibles:

  • “We see this from time to time. It’s not a big deal.”

  • “The gush is an indication that your fundus isn’t contracting.”

  • “Don’t worry. I’ll make sure everything is fine.”

  • “Blood has pooled in the vagina while you were in bed.”

Explicación

Pregunta 23 de 42

1

The postpartum nurse is caring for a first-time mother who is unable to breastfeed her baby. While assessing the patient’s breasts the day after birth, which teaching point should the nurse include?

Selecciona una de las siguientes respuestas posibles:

  • The let-down reflex

  • Lactation suppression

  • The purpose of fundal massage

  • The cause of afterpains

Explicación

Pregunta 24 de 42

1

Every time the nurse enters the room of a postpartum patient who gave birth three hours ago, the patient asks something else about her birth experience. The nurse would:

Selecciona una de las siguientes respuestas posibles:

  • Answer questions quickly and try to divert her attention to other subjects.

  • Review documentation of the birth experience and discuss it with her.

  • Contact the physician to warn him the patient might want to file a lawsuit due to her preoccupation with her birth experience.

  • Submit a referral to Social Services because you are concerned about obsessive behavior.

Explicación

Pregunta 25 de 42

1

During her interactions with a primipara mother, the nurse notices that the mother rarely interacts with the infant unless the infant begins to cry vigorously. She appears relieved when a nurse comes to check on the infant. What is the appropriate nursing intervention for this patient?

Selecciona una de las siguientes respuestas posibles:

  • Ask the mother if she has previous experience caring for babies, and then teach her how to interact appropriately with her infant.

  • Contact Social Services with concerns of neglect

  • Provide the care the infant needs while continuing to evaluate the mother’s actions

  • Take the infant to the nursery so it can receive more consistent care

Explicación

Pregunta 26 de 42

1

During the first several months after birth, the mother and infant begin to know each other. This relationship progresses through several phases. Which of the following actions are to be expected in the phase of mutual regulation?

Selecciona una de las siguientes respuestas posibles:

  • The infant grasps his or her mother’s finger while nursing.

  • The infant begins to seek out the mother over other individuals.

  • The mother spends more time making eye-to-eye contact with the infant

  • The mother vocalizes feelings of frustration with her infant.

Explicación

Pregunta 27 de 42

1

The nurse is to begin the postpartum teaching of a mother who has given birth to her first child. What aspect of teaching is most important?

Selecciona una de las siguientes respuestas posibles:

  • Describe the likely reaction of siblings to the new baby.

  • Discuss adaptation to grandparenthood by her parents

  • Determine if father–infant attachment is taking place

  • Assist the mother in identifying behavior cues of the baby

Explicación

Pregunta 28 de 42

1

The nurse is performing an assessment of early attachment. During the assessment, the nurse needs to answer the question “Does the mother seem pleased with her baby’s appearance and sex?” Which action of the mother might help answer this question?

Selecciona una de las siguientes respuestas posibles:

  • The mother enfolds the infant in her arms

  • The mother feeds the infant every 2-3 hours as instructed.

  • The mother points out family traits she sees in the newborn

  • The mother asks questions about how to properly bathe her infant.

Explicación

Pregunta 29 de 42

1

The nurse is preparing a community education class on healthy pregnancy. Which statements should be included?

Selecciona una o más de las siguientes respuestas posibles:

  • Eating a well-balanced diet helps prevent pregnancy complications

  • Stress management and support systems are important in pregnancy

  • Prenatal care can be obtained at any point in the pregnancy

  • Complications during a prior pregnancy do not recur.

  • Exercising regularly facilitates feeling better in pregnancy.

Explicación

Pregunta 30 de 42

1

A patient is 3 days postop from a cesarean birth. She has tenderness, localized heat, and redness of the left leg. She is afebrile. As a result of these symptoms, she most likely will be:

Selecciona una de las siguientes respuestas posibles:

  • 1. Encouraged to ambulate freely.

  • 2. Given aspirin 650 mg by mouth.

  • 3. Given Methergine IM.

  • 4. Placed on bed rest.

Explicación

Pregunta 31 de 42

1

The nurse is assisting a multiparous woman to the bathroom for the first time since her delivery 3 hours ago. When the patient stands up, blood runs down her legs and pools on the floor. The patient turns pale and feels weak. The first action of the nurse is to:

Selecciona una de las siguientes respuestas posibles:

  • 1. Assist the patient to empty her bladder.

  • 2. Help the patient back to bed to check her fundus.

  • 3. Assess her blood pressure and pulse.

  • 4. Begin an IV of Lactated Ringer’s infusion.

Explicación

Pregunta 32 de 42

1

A patient is experiencing excessive bleeding immediately after the birth of her newborn. After speeding up the IV fluids containing oxytocin, with no noticeable decrease in the bleeding, the nurse should anticipate the physician requesting which medications?

Selecciona una o más de las siguientes respuestas posibles:

  • Methergine

  • Stadol

  • Misoprostol

  • Betamethasone

Explicación

Pregunta 33 de 42

1

The postpartum patient who delivered 2 days ago has developed endometritis. Which charting entry would the nurse expect to find in this patient’s chart?

Selecciona una de las siguientes respuestas posibles:

  • 1. “Cesarean birth performed secondary to arrest of dilation.”

  • 2. “Rupture of membranes occurred 2 hours prior to delivery.”

  • 3. “External fetal monitoring used throughout labor.”

  • 4. “Patient has history of pregnancy-induced hypertension.”

Explicación

Pregunta 34 de 42

1

The patient at 3 days postpartum has come to the maternity clinic with complaints of urinary urgency and dysuria.
Which statement is most important for the nurse to make?

Selecciona una de las siguientes respuestas posibles:

  • 1. “Void into this sterile cup without touching the inside of the cup.”

  • 2. “Be sure to wipe from back to front after you have a bowel movement.”

  • 3. “Call the clinic if you develop nausea and vomiting or constipation.”

  • 4. “Decrease your fluid intake for a few days, but eat a lot of vegetables.”

Explicación

Pregunta 35 de 42

1

Which method of initial assessment would best indicate whether a patient has a urinary complication?

Selecciona una de las siguientes respuestas posibles:

  • 1. Urine pH

  • 2. Calculation of urine output

  • 3. Urine-specific gravity

  • 4. Calculation of intake

Explicación

Pregunta 36 de 42

1

The postpartum multipara is breastfeeding her new baby. The patient states that she developed mastitis with her
first child, and asks if there is something she can do to prevent mastitis this time. The best response of the nurse
is:

Selecciona una de las siguientes respuestas posibles:

  • 1. “Massage your breasts on a daily basis, and if you find a hardened area, massage it towards the nipple to
    unblock that duct.”

  • 2. “Most first-time moms experience mastitis. It is really quite unusual for a woman having her second baby to get
    it again.”

  • 3. “Apply cold packs to any areas that feel thickened or firm in order to relieve the swelling and stasis of the milk
    in that area.”

  • 4. “Take your temperature once a day. This will help you to pick up the infection early, before it becomes severe.”

Explicación

Pregunta 37 de 42

1

A nurse suspects that a postpartum patient has mastitis. The following assessment provides what data to support
this assessment?

Selecciona una o más de las siguientes respuestas posibles:

  • 1. Shooting pain in her nipple during breastfeeding.

  • 2. Late onset of nipple pain

  • 3. Pink, flaking, pruritic skin of the affected nipple.

  • 4. Nipple soreness when the infant latches on.

Explicación

Pregunta 38 de 42

1

The postpartum patient has developed thrombophlebitis in her right leg. Which finding requires immediate
intervention? The patient:

Selecciona una de las siguientes respuestas posibles:

  • 1. The postpartum patient has developed thrombophlebitis in her right leg. Which finding requires immediate
    intervention? The patient:

  • 2. Develops pain and swelling in her left lower leg.

  • 3. Appears anxious, and describes pressure in her chest.

  • 4. Becomes upset that she can’t go home yet.

Explicación

Pregunta 39 de 42

1

The nurse is revising the care plan of a 26-year-old woman who has developed mastitis. Which nursing diagnosis
is most appropriate for inclusion in this patient’s updated plan of care?

Selecciona una de las siguientes respuestas posibles:

  • 1. Ineffective Peripheral Tissue Perfusion related to obstructed venous return

  • 2. Risk for Trauma related to lack of information about appropriate breastfeeding practices.

  • 3. Deficient Knowledge related to self-care after discharge on anticoagulant therapy

  • 4. Acute Pain related to tissue hypoxia and edema secondary to vascular obstruction

Explicación

Pregunta 40 de 42

1

The nurse is calling postpartum patients. Which patient should be seen immediately? The patient at 4 weeks
postpartum who:

Selecciona una de las siguientes respuestas posibles:

  • 1. Describes feeling sad all the time.

  • 2. Reports hearing voices talking about the baby.

  • 3. States she has no appetite and wants to sleep all day.

  • 4. Says she needs a refill on her sertraline (Zoloft) next week.

Explicación

Pregunta 41 de 42

1

The maternal nurse educator is conducting a presentation for antepartum patients describing the identification and care of women diagnosed with postpartum psychiatric disorders. Which information should the maternal nurse educator include in her teaching content?

Selecciona una de las siguientes respuestas posibles:

  • 1. Postpartum depression occurs in as many as 50% to 70% of mothers and is characterized by mild depression interspersed with happier feelings.

  • 2. Postpartum depression is typically mild and usually self-limiting, lasting up to 6 weeks.

  • 3. Even if she is asymptomatic, a woman with a history of postpartum depression should be referred to a mental health professional for counseling and biweekly visits postpartum

  • 4. Women with postpartum depression have a history of exposure to an extremely traumatic personal event that involves actual or threatened death or serious injury and evokes intense fear, helplessness, or horror.

Explicación

Pregunta 42 de 42

1

The charge nurse is reviewing the plan of care for maternal patients currently admitted for postpartum care. During the course of her chart review, which intervention requires immediate consideration for revision?

Selecciona una de las siguientes respuestas posibles:

  • 1. Daily prothrombin time (PT) measurements for coagulation assessment in a woman receiving heparin for treatment of thrombophlebitis

  • 2. Use of the REEDA scale for assessment every 8 hours in the care of a patient diagnosed with puerperal infection

  • 3. Misoprostol (Cytotec) administration to a patient who demonstrates uterine atony and bleeding after receiving oxytocic medications

  • 4. Inserting a straight catheter to drain the overdistended bladder of a woman during the early postpartum period of her care.

Explicación

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