81. Twenty-four hours after uncomplicated labor and delivery, the mother’s CBC revels WBC of 17,000/mm3. The nurse would interpret the woman’s WBC count as being indicative of:
- A bacterial infection of the reproductive system
- An acute sexually transmitted viral disease
C. A normal decrease in WBC
- A normal response to labor process
82. Which of the following statement best describe puerperium?
- 4-6 hours period after delivery during which the placenta is completely expelled
- A phase of the fourth stage of labor
- A term to indicate progressive changes of the breast 4 to 6 weeks after delivery
- A 6 week period after delivery, during which the reproductive organs return to non-pregnant state
83. A woman G1P1 delivered a 7-lb male infant. She plans to breast feed the baby. On the first day postpartum day, the nurse notes that the woman’s fundus is above the umbilicus and to the left of the midline. What would the nurse initially suspect?
A. A full bladder
B. Retained placental fragments
C. Uterine atony
D. Uterine inertia
84. Ellen complains of tenderness and swelling of the breasts. The nurse explains that she is experiencing primary breast engorgement, which lasts for
A. 1 to 2 days
B. 3 to 4 days
C. 5 to 6 days
D. 7 to 8 days
85. Which of the following would the nurse teach the postpartum woman to include in her daily care to keep the nipples in good condition for breastfeeding to prevent potential for infection?
A. Wash with soap and water before each feeding
B. Keep the nipples dry and clean
C. Cover the nipples with a dry and clean plastic pad
D. Cleanse with antiseptic solution three times a day
86. Which of the following statement best explain why the postpartum mother voids large amount of urine frequently?
A. A sign of urinary retention and overflow
B. A normal body’s response to reduce extracellular fluid acquired during pregnancy
C. A result of decreased bladder tone due to anesthesia during labor
D. An indication of a bladder infection
87. The period immediately following birth is divided into significant phases. The phase in which the mother’s needs have to be met before she can meet the baby’s needs is called
A. Taking-in phase
- Transition phase
- Taking-hold phase
- Bonding phase
88. A woman is discharged on her third postpartum day. What type of lochia should be noted?
A. Lochia alba
B. Lochia serosa
- Lochia rubra
- Lochia rugae
89. If the fundus of the uterus is felt at the umbilicus immediately after delivery of the placenta,
the nurse should take which one of the following nursing actions?
- Catheterize the patient
B. Massage the fundus to make it firm
- Administer Methergine
- Support the mother, because this represents a normal fundus placement
90. Two days after delivery, the nurse assesses a heavy amount of lochia rubra containing
four blood clots about the size of one-peso coin. This assessment is:
- Abnormal because it is lochia serosa
D. A sign of complication or hemorrhage
91. Which one of the following conditions would alert the nurse for a possible postpartum hemorrhage?
A. Delivery of twins after 16 hours of labor
- Cesarean birth
- Premature delivery
- First delivery of 7 lb baby boy 2 hours after rupture of membranes
92. In explaining the pattern of discharge following delivery, the nurse explains that lochia will
be heavier:
A. In the morning
- At night
- As lochia cessation nears
- Toward the end of lactation
93. Which hormone works with estrogen and progesterone to stimulate the breast? development and milk production during pregnancy and following pregnancy?
- FSH
- Oxytocin
C. Prolactin
D. Placental lactogen
94. The first day after delivery, the husband tells the nurse that his wife has been talking constantly about her recent delivery experience. He asks the nurse if this is normal maternal behavior after delivery. The nurse’s best response is:
- Divert her attention away from the delivery
- Do you feel uncomfortable talking about the delivery experience?
C. This is a normal reaction; it allows her to accept the reality of birth
- It’s a clear sign that your wife needs psychiatric evaluation
95. A mother plans to bottle-feed her son. She asks the nurse when her menstruation will return. The nurse
correctly states that non-breastfeeding mothers typically resume menstruating in about:
- 4 to 6 weeks
B. 6-8 weeks
- 3-6 months
- 4-8 month
96. The major reason for a 3-week prescription for resumption of sexual intercourse is to prevent
- Tearing of the episiotomy
B. Vaginal and cervical infection
- Bladder infection
- Dyspareunia
97. After uncomplicated vaginal delivery the mother complains of severe cramping. The nurse knows that such cramping commonly associated with
- Infection
- Retained placental fragments
C. Uterine involution
- Bladder distension
98. The nurse prepares to help the mother ambulate for the first time after vaginal delivery. Which statement about early ambulation is true?
A. It may cause hypotensive episodes
- It facilitates uterine involution
- It requires no special nursing intervention
- It should not be attempted for at least 10 hours after delivery
99. The nurse should assess for a functional let-down reflex. Which sign indicates that the mother’s let-down
is functioning properly?
A. The neonate’s vigorous sucking at the breast
B. Nipple soreness
C. Leakage of milk from one breast while the neonate nurses at the other breast
D. A feeling of breast fullness
100. After 2 breastfeeding sessions, the mother tells the nurse, “when I breastfeed my baby, the cramping gets much worse.” T he nurse’s best response is:
A. Breastfeeding cause the uterus to contract. I can give you something for pain before you breastfeed
B. Let me watch while you breastfeed; your technique may be causing this problem
C. The cramping is normal, but you can not take any medication while you are breastfeeding
D. The cramping will pass. You just need to continue with the breastfeeding
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