NCLEX Exam: Obstetrical Nursing Postpartum (55 Items) 1 ! postpartum nurse is preparing to care "or a #oman #$o $as %ust &eli'ere& a $ealt$( ne#born in"ant In t$e imme&iate postpartum perio& t$e nurse plans to ta)e t$e #oman*s 'ital signs:1. Every 30 minutes during the first hour and then every hour for the next two hours.2. Every 15 minutes during the first hour and then every 30 minutes for the next two hours.3. Every hour for the first 2 hours and then every 4 hours4. Every 5 minutes for the first 30 minutes and then every hour for the next 4 hours.+ ! postpartum nurse is ta)ing t$e 'ital signs o" a #oman #$o &eli'ere& a $ealt$( ne#born in"ant , $ours ago -$e nurse notes t$at t$e mot$er*s temperature is 1..+/0 1$ic$ o" t$e "ollo#ing actions #oul& be most appropriate21. Retake the temperature in 15 minutes2. Notify the physiian3. !oument the findings4. "nrease hydration #y enouraging ora$ f$uids3 -$e nurse is assessing a client #$o is 4 $ours PP a"ter &eli'ering a "ull5term $ealt$( in"ant -$e client complains to t$e nurseo" "eelings o" "aintness an& &i66iness 1$ic$ o" t$e "ollo#ing nursing actions #oul& be most appropriate21. %#tain hemog$o#in and hematorit $eve$s2. "nstrut the mother to re&uest he$p when getting out of #ed3. E$evate the mother's $egs4. "nform the nursery room nurse to avoid #ringing the new#orn infant to the mother unti$ the fee$ings of $ightheadedness and di((iness have su#sided., ! nurse is preparing to per"orm a "un&al assessment on a postpartum client -$e initial nursing action in per"orming t$is assessment is #$ic$ o" t$e "ollo#ing21. )sk the $ient to turn on her side2. )sk the $ient to $ie f$at on her #ak with the knees and $egs f$at and straight.3. )sk the mother to urinate and empty her #$adder4. *assage the fundus gent$y #efore determining the $eve$ of the fundus.5 -$e nurse is assessing t$e loc$ia on a 1 &a( PP patient -$e nurse notes t$at t$e loc$ia is re& an& $as a "oul5smelling o&or -$e nurse &etermines t$at t$is assessment "in&ing is:1. Norma$2. "ndiates the presene of infetion3. "ndiates the need for inreasing ora$ f$uids4. "ndiates the need for inreasing am#u$ation4 1$en per"orming a PP assessment on a client7 t$e nurse notes t$e presence o" clots in t$e loc$ia -$e nurse examines t$e clots an& notes t$at t$e( are larger t$an 1 cm 1$ic$ o" t$e "ollo#ing nursing actions is most appropriate21. !oument the findings2. Notify the physiian3. Reassess the $ient in 2 hours4. Enourage inreased intake of f$uids.8 ! nurse in a PP unit is instructing a mot$er regar&ing loc$ia an& t$e amount o" expecte& loc$ia &rainage -$e nurse instructs t$e mot$er t$at t$e normal amount o" loc$ia ma( 'ar( but s$oul& ne'er excee& t$e nee& "or:1. %ne peripad per day2. +wo peripads per day3. +hree peripads per day4. Eight peripads per day9 ! PP nurse is pro'i&ing instructions to a #oman a"ter &eli'er( o" a $ealt$( ne#born in"ant -$e nurse instructs t$e mot$er t$at s$e s$oul& expect normal bo#el elimination to return:1. %ne the day of the de$ivery2. 3 days ,,3. - days ,,4. within 2 weeks ,,: ;elect all o" t$e p$(siological maternal c$anges t$at occur &uring t$e PP perio&1. .ervia$ invo$ution eases immediate$y2. /agina$ distention dereases s$ow$y3. 0undus #egins to desend into the pe$vis after 24 hours4. .ardia output dereases with resu$tant tahyardia in the first 24 hours5. !igestive proesses s$ow immediate$y.1. ! nurse is caring "or a PP #oman #$o $as recei'e& epi&ural anest$esia an& is monitoring t$e #oman "or t$e presence o" a 'ul'a $ematoma 1$ic$ o" t$e "ollo#ing assessment "in&ings #oul& best in&icate t$e presence o" a $ematoma21. .omp$aints of a tearing sensation2. .omp$aints of intense pain3. .hanges in vita$ signs4. 1igns of heavy #ruising11 ! nurse is &e'eloping a plan o" care "or a PP #oman #it$ a small 'ul'ar $ematoma -$e nurse inclu&es #$ic$ speci"ic inter'ention in t$e plan &uring t$e "irst 1+ $ours "ollo#ing t$e &eli'er( o" t$is client21. )ssess vita$ signs every 4 hours2. "nform hea$th are provider of assessment findings3. *easure funda$ height every 4 hours4. ,repare an ie pak for app$iation to the area.1+ ! ne# mot$er recei'e& epi&ural anest$esia &uring labor an& $a& a "orceps &eli'er( a"ter pus$ing + $ours !t 4 $ours PP7 $er s(stolic bloo& pressure $as &roppe& +. points7 $er &iastolic - -$e nurse un&erstan&s t$at t$e client*s response to treatment #ill be e'aluate& b( regularl( assessing t$e client "or:1. !ysuria7 ehymosis7 and vertigo2. Epistaxis7 hematuria7 and dysuria3. 6ematuria7 ehymosis7 and epistaxis4. 6ematuria7 ehymosis7 and vertigo19 ! nurse per"orms an assessment on a client #$o is , $ours PP -$e nurse notes t$at t$e client $as cool7 clamm( s)in an& is restless an& excessi'el( t$irst( -$e nurse prepares imme&iatel( to:1. )ssess for hypovo$emia and notify the hea$th are provider2. 4egin hour$y pad ounts and reassure the $ient3. 4egin funda$ massage and start oxygen #y mask4. E$evate the head of the #ed and assess vita$ signs1: ! nurse is assessing a client in t$e ,t$ stage i" labor an& notes t$at t$e "un&us is "irm but t$at blee&ing is excessi'e -$e initial nursing action #oul& be #$ic$ o" t$e "ollo#ing21. *assage the fundus2. ,$ae the mother in the +rende$en#urg's position3. Notify the physiian4. Reord the findings+. ! nurse is caring "or a PP client #it$ a &iagnosis o" =>- #$o is recei'ing a continuous intra'enous in"usion o" $eparin so&ium 1$ic$ o" t$e "ollo#ing laborator( results #ill t$e nurse speci"icall( re'ie# to &etermine i" an e""ecti'e an& appropriate &ose o" t$e $eparin is being &eli'ere&21. ,rothrom#in time2. "nternationa$ norma$i(ed ratio3. )tivated partia$ throm#op$astin time4. ,$ate$et ount+1 ! nurse is preparing a list o" sel"5care instructions "or a PP client #$o #as &iagnose& #it$ mastitis ;elect all instructions t$at #oul& be inclu&e& on t$e list1. +ake the presri#ed anti#iotis unti$ the soreness su#sides.2. ;ear supportive #ra3. )void deompression of the #reasts #y #reastfeeding or #reast pump4. Rest during the aute phase5. .ontinue to #reastfeed if the #reasts are not too sore.++ ?et$ergine or pitocin is prescribe& "or a #oman to treat PP $emorr$age