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postpartum patient/ s/s and positions

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1 postpartum patient/ s/s and positions on Mon Nov 07, 2011 11:39 pm

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1.The two most important predisposing causes of postpartum infection are:
A. Hemorrhage and trauma during labor
B. Preeclampsia and retention of placenta
C. Malnutrition and anemia during pregnancy
D. Organisms present in the birth canal and trauma during labor
A&D

2. Intake and output are important in the early postpartum period because small amounts of output:
A. May indicate retention of urine with overflow
B. Are commonly voided and should cause no alarm
C. May be indicative of beginning glomerulonephritis
D. Are common because less fluid is excreted following delivery
A

3. When checking a clients fundus on the second postpartum day the nurse observes that the fundus is above the umbilicus and displaced to the right. The nurse evaluates that the client probably has:
A. A slow rate of involution
B. A full overdistended bladder
C. Retained placental fragments
D. Overstretched uterine ligaments
B

4. During the postpartum period after a cesarean birth, the nurse examines the client and identifies the presence of lochia serosa and feels the fundus four fingerbreadths below the umbilicus. This indicates that the time elapsed is:
A. 1 to 3 days postpartum
B. 4 to 5 days "
C. 6 to 7 days "
D. 8 to 9 days "
B

5. The pituitary hormone that stimulates the secretion of mild from the mammary glands is:
A. Prolactin
B. Oxytocin
C. Estrogen
D. Progesterone
A

6. The nurse is aware that one of the factors influencing the availability of mild in the lactating woman is the:
A. Amount of erectile tissue in the nipples
B. Age of the woman at the time of delivery
C. Attitude of the womans family toward breastfeeding
D. Amount of milk and milk products consumed during pregnancy
C
7. When caring for a client with an episiotomy during the postpartum period, the nurse encourages sitz baths three times a day for 15 min, Sitx baths primarily aid the healing process by:
A. Promoting vasodilation
B. Softening the incision site
C. Cleansing the perineal area
D. Tightening the rectal sphincter
A

8. The nurse working on the postpartum unit should encourage clients to ambulate early to:
A. Promote respirations
B. Increase the tone of the bladder
C. Maintain tone of abdominal muscles
D. Increase peripheral vasomotor activity
D

9. When performing discharge teaching for a postpartum client, the nurse should inform her that:
A. The episiotomy sutures will be removed at the first postpartum checkup
B. She may not have any bowel movements for up to a week after the birth
C. She has to schedule a postpartum checkup as soon as her menses returns
D. The perineal tightening exercises started during pregnancy should be continued indefinitely
D

10. The nurse should teach the client that breastfeeding is always contraindicated with:
A. Mastitis
B. Hepatitis C
C. Inverted nipples
D. Herpes genitalis
B

11. The client response that indicates correct understanding of teaching regarding breast care in the mother who is breastfeeding would be "I will":
A. Use a mild soap for washing
B. Remove my brassiere at night
C. Air dry my nipples after feeding
D. Line my breast pads with plastic
C

12. When teaching breastfeeing the nurse should recognize the client needs further instructions when she states "I will":
A. Use an alternate breast at each feeding
B. Try to empty my breasts at each feeding
C. Wash my breasts with water before each feeding
D. Wash my breast with soap and water before feeding
D

13. During the postpartum period, a client tells the nurse she is having leg cramps. The nurse should suggest that the client increase her intake of:
A. Eggs and bacon
B. Liver and onions
C. Juices and water
D. Cheese and broccoli
D

14. The nurse teaches a multipara who has just delivered a large baby what to do to maintain a contracted uterus. The nurse recognizes that teaching has been effective when the client states:
A. If i start to bleed, I will call for help
B. I will gently massage my uterus to keep it firm
C. If I urinate frequently, my uterus will stay contracted
D. I will call you every 15 min to massage my uterus
B

15. A client asks about the difference between cow's milk and the milk from her breasts. The nurse should respond that cow's milk differs from human milk in that it contains:
A. More protein, less calcium, and less carbohydrate
B. Less protein, less calcium, and more carbohydrate
C. More protein, more calcium, and less carbohydrate
D. Less protein, more calcium, and more carbohydrate
C

References: Mosby's Comprehensive Review of Nursing for the NCLEX-RN Examination (Saxton, Nugent, and Pelikan)

S/S of Increased Intracranial Pressure
#1 Decreased level of consciousness
#2 Nausea and vomiting
#3 Changes in speech
#4 Seizures
#5 Cushing's triad

With a patient with increased ICP, avoid neck flexion, extreme hip/knee flexion, or long periods of sitting or standing

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