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■ 3. Class III. ■ 4. Class IV. 69. A primigravid client has completed her fi rst prenatal visit and blood work. Her laboratory test for the hepatitis B surface antigen (HBsAg) is positive. The nurse can advise the client that the plan of care for this newborn will include? Select all that apply. ■ 1. Hepatitis B immune globulin at birth. ■ 2. Series of three hepatitis B vaccinations per recommended schedule. ■ 3. Hepatitis B screening when born. ■ 4. Isolation of infant during hospitalization. ■ 5. Universal precautions for mother and infant. ■ 6. Contraindication for breast-feeding because the mother is HBsAg positive. 70. A woman who has had asthma since she was a child and it is under control when the client takes her medication correctly and consistently is now pregnant for the fi rst time. Which of the following client statements concerning asthma during pregnancy indicates the need for further instruction? ■ 1. “I need to continue taking my asthma medication as prescribed.” ■ 2. “It is my goal to prevent or limit asthma attacks.” ■ 3. “During an asthma attack, oxygen needs continue to be high for mother and fetus.” ■ 4. “Bronchodilators should be used only when necessary because of the risk they present to the fetus.” 71. To decrease the possibility of a perineal laceration during delivery, the nurse performs which of the following interventions prior to the delivery? 1. Assists the woman into a squatting position. 2. Advises the woman to push only when she feels the urge. 3. Encourages the woman to push slowly and steadily. 4. Massages the perineum with mineral oil. 72. The nurse is performing a vaginal examination on a client in labor. The client is found to be 5 cm dilated, 90% effaced, and station 2. Which of the following has the nurse palpated? 1. Thin cervix. 2. Bulging fetal membranes. 3. Head at the pelvic outlet. 4. Closed cervix. 73. A couple has delivered a 28-week fetal demise. Which of the following nursing actions are appropriate to take? Select all that apply. 1. Swaddle the baby in a baby blanket. 2. Discuss funeral options for the baby. 3. Encourage the couple to try to get pregnant again soon. 4. Ask the couple whether or not they would like to hold the baby. 5. Advise the couple that the baby’s death was probably for the best. 74. A client is being discharged on Coumadin (warfarin) post– pulmonary embolism after a cesarean delivery. Which of the following should be included in the patient teaching? 1. Only take ibuprofen for pain. 2. Avoid eating dark green leafy vegetables. 3. Drink grapefruit juice daily. 4. Report any decrease in urinary output. 376 MATERNALAND NEWBORN SUCCESS 75. A client just delivered the placenta pictured below. For which of the following complications should the nurse carefully observe the woman? 1. Endometrial ischemia. 2. Postpartum hemorrhage. 3. Prolapsed uterus. 4. Vaginal hematoma. 76. Which of the following is a priority nursing diagnosis for a woman, G10P6226, who is PP1 from a spontaneous vaginal delivery with a significant postpartum hemorrhage? 1. Alteration is comfort related to afterbirth pains. 2. Risk for altered parenting related to grand multiparity. 3. Fluid volume deficit related to blood loss. 4. Risk for sleep deprivation related to mothering role. 77. A woman has just had a macrosomic baby after a 12-hour labor. For which of the following complications should the woman be carefully monitored? 1. Uterine atony. 2. Hypoprolactinemia. 3. Infection. 4. Mastitis. 78. On admission to the labor and delivery suite, the nurse assesses the discharge needs of a primipara who will be discharged home 4 days after a cesarean delivery. Which of the following questions should the nurse ask the client? 1. “Have you ever had anesthesia before?” 2. “Do you have any allergies?” 3. “Do you scar easily?” 4. “Are there many stairs in your home?” 79. A woman is receiving Paxil (paroxetine) for postpartum depression. In order to prevent a drug/food interaction, the client must be advised to refrain from consuming which of the following? 1. Alcohol. 2. Grapefruit. 3. Milk. 4. Cabbage. 80. A nurse is assessing a 1 day-postpartum client who had a spontaneous vaginal delivery over an intact perineum. The fundus is firm at the umbilicus, lochia moderate, and perineum edematous. One hour after receiving ibuprofen 600 mg po, the client is complaining of perineal pain at level 9 on a 10 point scale. Based on this information, which of the following is an appropriate conclusion for the nurse to make about the client? 1. She should be assessed by her doctor. 2. She should have a sitz bath. 3. She may have a hidden laceration. 4. She needs a narcotic analgesic. 81. A breastfeeding mother calls the obstetrician’s office with a complaint of pain in one breast. Upon inspection, a diagnosis of mastitis is made. Which of the following nursing interventions is appropriate? 1. Advise the woman to apply ice packs to her breasts. 2. Encourage the woman to breastfeed frequently. 3. Inform the woman that she should wean immediately. 4. Direct the woman to notify her pediatrician as soon as possible. 82. A woman, who wishes to breastfeed, advises the nurse that she has had breast augmentation surgery. Which of the following responses by the nurse is appropriate? 1. Breast implants often contaminate the milk with toxins. 2. The glandular tissue of women who need implants is often deficient. 3. Babies often have difficulty latching to the nipples of women with breast implants. 4. Women who have implants are often able exclusively to breastfeed. 83. A breastfeeding client calls her obstetrician stating that her baby was diagnosed with thrush and that her breasts have become infected as well. Which of the following organisms has caused the baby’s and mother’s infection? 1. Staphylococcus aureus. 2. Streptococcus pneumonia. 3. Escherichia coli. 4. Candida albicans. 84. A client is on magnesium sulfate via IV pump for severe preeclampsia. Other than patellar reflex assessments, which of the following noninvasive assessments should the nurse perform to monitor the client for early signs of magnesium sulfate toxicity? 1. Serial grip strengths. 2. Kernig assessments. 3. Pupillary responses. 4. Apical heart rate checks. 85. A woman, 26 weeks’ gestation, has just delivered a fetal demise. Which of the following nursing actions is appropriate at this time? 1. Remind the mother that she will be able to have another baby in the future. 2. Dress the baby in a tee shirt and swaddle the baby in a receiving blanket. 3. Ask the woman if she would like the doctor to prescribe a sedative for her. 4. Remove the baby from the delivery room as soon as possible. 86. A client, G1P0000, is PP1 from a normal spontaneous delivery of a baby boy, Apgar 5/6. Because the client exhibited addictive behaviors, a toxicology assessment was performed; the results were positive for alcohol and cocaine. Which of the following interventions is appropriate for this postpartum client? 1. Strongly advise the client to breastfeed her baby. 2. Perform hourly incentive spirometer respiratory assessments. 3. Suggest that the nursery nurse feed the baby in the nursery. 4. Provide the client with supervised instruction on baby care skills. 87. A client is 10 minutes postpartum from a forceps delivery of a 4500-gram Down syndrome neonate over a right mediolateral episiotomy. The client is at risk for each of the following nursing diagnoses. Which of the diagnoses is highest priority at this time? 1. Ineffective breastfeeding. 2. Fluid volume deficit. 3. Infection. 4. Pain. 88. A client is postpartum 24 hours from a spontaneous vaginal delivery with rupture of membranes for 42 hours. Which of the following signs/symptoms should the nurse report to the client’s health care practitioner? 1. Foul-smelling lochia. 2. Engorged breasts. 3. Cracked nipples. 4. Cluster of hemorrhoids. 89. A client is 36 hours post–cesarean section. Which of the following assessments would indicate that the client may have a paralytic ileus? 1. Abdominal striae. 2. Oliguria. 3. Omphalocele. 4. Absent bowel sounds. 90. A client, 1 day postpartum (PP), is being monitored carefully after a significant postpartum hemorrhage. Which of the following should the nurse report to the obstetrician? 1. Urine output 200 mL for last 8 hours. 2. Weight decrease of 2 pounds since delivery. 3. Drop in hematocrit of 2% since admission. 4. Pulse rate of 68 beats per minute. 91. A nurse is working on the postpartum unit. Which of the following patients should the nurse assess first? 1. PP1 from vaginal delivery complains of burning on urination. 2. PP1 from forceps delivery with blood loss of 500 mL at time of delivery. 3. PP3 from vacuum delivery with hemoglobin of 7.2 g/dL. 4. PO3 from cesarean delivery complains of firm and painful breasts. 92. A nurse has administered Methergine (methylergonovine) 0.2 mg po to a grand multipara who delivered vaginally 30 minutes earlier. Which of the following outcomes indicates that the medication is effective? 1. Blood pressure 120/80. 2. Pulse rate 80 bpm and regular. 3. Fundus firm at umbilicus. 4. Increase in prothrombin time. 93. A nurse on the postpartum unit is caring for two postoperative cesarean clients. One client had spinal anesthesia for the delivery while the other client had an epidural. Which of the following complications will the nurse monitor the spinal client for that the epidural client is much less high risk for? 1. Pruritus. 2. Nausea. 3. Postural headache. 4. Respiratory depression. 94. A postpartum woman has been diagnosed with postpartum psychosis. Which of the following signs/symptoms would the client exhibit? 1. Hallucinations. 2. Polyphagia. 3. Induced vomiting. 4. Weepy sadness. 95. The nurse is providing discharge counseling to a woman who is breastfeeding her baby. What should the nurse advise the woman to do if she should palpate tender, hard nodules in her breasts?