Ricci Chapter 22 - Test Bank - 4th Edition

1. Review of a primiparous woman's labor and birth record reveals a prolonged second stage of

labor and extended time in the stirrups. Based on an interpretation of these findings, the nurse

would be especially alert for which condition?

A. retained placental fragments

B. hypertension

C. thrombophlebitis

D. uterine subinvolution

Answer: C

Rationale: The woman is at risk for thrombophlebitis due to the prolonged second stage of labor,

necessitating an increased amount of time in bed, and venous pooling that occurs when the

woman's legs are in stirrups for a long period of time. These findings are unrelated to retained

placental fragments, which would lead to uterine subinvolution, or hypertension.

2. The nurse is conducting a class for postpartum women about mood disorders. The nurse

describes a transient, self-limiting mood disorder that affects mothers after birth. The nurse

determines that the women understood the description when they identify the condition as

postpartum:

A. depression.

B. psychosis.

C. bipolar disorder.

D. blues.

Answer: D

Rationale: Postpartum blues are manifested by mild depressive symptoms of anxiety, irritability,

mood swings, tearfulness, increased sensitivity, feelings of being overwhelmed, and fatigue.

They are usually self-limiting and require no formal treatment other than reassurance and

validation of the woman's experience as well as assistance in caring for herself and her newborn.

Postpartum depression is a major depressive episode associated with birth. Postpartum psychosis

is at the severe end of the continuum of postpartum emotional disorders. Bipolar disorder refers

to a mood disorder typically involving episodes of depression and mania.

3. A woman who is 2 weeks postpartum calls the clinic and says, "My left breast hurts." After

further assessment on the phone, the nurse suspects the woman has mastitis. In addition to pain,

the nurse would question the woman about which symptom?

A. an inverted nipple on the affected breast

B. no breast milk in the affected breast

C. an ecchymotic area on the affected breast

D. hardening of an area in the affected breast

Answer: D

Rationale: Mastitis is characterized by a tender, hot, red, painful area on the affected breast. An

inverted nipple is not associated with mastitis. With mastitis, the breast is distended with milk,

the area is inflamed (not ecchymotic), and there is breast tenderness.

4. A nurse is developing a program to help reduce the risk of late postpartum hemorrhage in

clients in the labor and birth unit. Which measure would the nurse emphasize as part of this

program?

A. administering broad-spectrum antibiotics

B. inspecting the placenta after delivery for intactness

C. manually removing the placenta at birth

D. applying pressure to the umbilical cord to remove the placenta

Answer: B

Rationale: After the placenta is expelled, a thorough inspection is necessary to confirm its

intactness because tears or fragments left inside may indicate an accessory lobe or placenta

accreta. These can lead to profuse hemorrhage because the uterus is unable to contract fully.

Administering antibiotics would be appropriate for preventing infection, not postpartum

hemorrhage. Manual removal of the placenta or excessive traction on the umbilical cord can lead

to uterine inversion, which in turn would result in hemorrhage.

5. A multipara client develops thrombophlebitis after birth. Which assessment findings would

lead the nurse to intervene immediately?

A. dyspnea, diaphoresis, hypotension, and chest pain

B. dyspnea, bradycardia, hypertension, and confusion

C. weakness, anorexia, change in level of consciousness, and coma

D. pallor, tachycardia, seizures, and jaundice

Answer: A

Rationale: Sudden unexplained shortness of breath and reports of chest pain along with

diaphoresis and hypotension suggest pulmonary embolism, which requires immediate action.

Other signs and symptoms include tachycardia, apprehension, hemoptysis, syncope, and sudden

change in the woman's mental status secondary to hypoxemia. Anorexia, seizures, and jaundice

are unrelated to a pulmonary embolism.

6. A client experienced prolonged labor with prolonged premature rupture of membranes. The

nurse would be alert for which condition in the mother and the newborn?

A. infection

B. hemorrhage

C. trauma

D. hypovolemia

Answer: A

Rationale: Although hemorrhage, trauma, and hypovolemia may be problems, the prolonged

labor with the prolonged premature rupture of membranes places the client at high risk for a

postpartum infection. The rupture of membranes removes the barrier of amniotic fluid, so

bacteria can ascend.

7. When assessing the postpartum woman, the nurse uses indicators other than pulse rate and

blood pressure for postpartum hemorrhage because:

A. these measurements may not change until after the blood loss is large.

B. the body's compensatory mechanisms activate and prevent any changes.

C. they relate more to change in condition than to the amount of blood lost.

D. maternal anxiety adversely affects these vital signs.

Answer: A

Rationale: The typical signs of hemorrhage do not appear in the postpartum woman until as

much as 1,800 to 2,100 ml of blood has been lost. In addition, accurate determination of actual

blood loss is difficult because of blood pooling inside the uterus and on perineal pads,

mattresses, and the floor.

8. A nurse is assessing a postpartum client. Which finding would the cause the nurse the greatest

concern?

A. leg pain on ambulation with mild ankle edema

B. calf pain with dorsiflexion of the foot

C. perineal pain with swelling along the episiotomy

D. sharp, stabbing chest pain with shortness of breath

Answer: D

Rationale: Sharp, stabbing chest pain with shortness of breath suggests pulmonary embolism, an

emergency that requires immediate action. Leg pain on ambulation with mild edema suggests

superficial venous thrombosis. Calf pain on dorsiflexion of the foot may indicate deep vein

thrombosis or a strained muscle or contusion. Perineal pain with swelling along the episiotomy

might be a normal finding or suggest an infection. Of the conditions, pulmonary embolism is the

most urgent.

9. A woman who is experiencing postpartum hemorrhage is extremely apprehensive and

diaphoretic. The woman's extremities are cool and her capillary refill time is increased. Based on

this assessment, the nurse suspects that the client is experiencing approximately how much blood

loss?

A. 20%

B. 30%

C. 40%

D. 60%

Answer: D

Rationale: The client's assessment indicated mild shock, which is associated with a 20% blood

loss. Moderate shock occurs with a blood loss of 30 to 40%. Severe shock is associated with a

blood loss greater than 40%.

10. A postpartum client is prescribed medication therapy as part of the treatment plan for

postpartum hemorrhage. Which medication would the nurse expect to administer in this

situation?

A. Magnesium sulfate

B. methylergonovine

C. Indomethacin

D. nifedipine

Answer: B

Rationale: Methylergonovine, along wiht oxytocin and carboprost are drugs used to manage

postpartum hemorrhage. Magnesium sulfate, indomethecin, and nifedipine are used to control

preterm labor.

11. A client is experiencing postpartum hemorrhage, and the nurse begins to massage her fundus.

Which action would be most appropriate for the nurse to do when massaging the woman's

fundus?

A. Place the hands on the sides of the abdomen to grasp the uterus.

B. Use an up-and-down motion to massage the uterus.

C. Wait until the uterus is firm to express clots.

D. Continue massaging the uterus for at least 5 minutes.

Answer: C

Rationale: The uterus must be firm before attempts to express clots are made because application

of firm pressure on an uncontracted uterus could lead to uterine inversion. One hand is placed on

the fundus and the other hand is placed on the area above the symphysis pubis. Circular motions

are used for massage. There is no specified amount of time for fundal massage. Uterine tissue

responds quickly to touch, so it is important not to overmassage the fundus.

12. After teaching a woman with a postpartum infection about care after discharge, which client

statement indicates the need for additional teaching?

A. "I need to call my doctor if my temperature goes above 100.4° F (38° C)."

B. "When I put on a new pad, I'll start at the back and go forward."

C. "If I have chills or my discharge has a strange odor, I'll call my doctor."

D. "I'll point the spray of the peri-bottle so it the water flows front to back."

Answer: B

Rationale: The woman needs additional teaching when she states that she should apply the

perineal pad starting at the back and going forward. The pad should be applied using a front-toback

motion. Notifying the health care provider of a temperature above 100.4° F (38° C), aiming

the peri-bottle spray so that the flow goes from front to back, and reporting danger signs such as

chills or lochia with a strange odor indicate effective teaching.

13. A nurse is making a home visit to a postpartum client. Which finding would lead the nurse to

suspect that a woman is experiencing postpartum psychosis?

A. delirium

B. feelings of guilt

C. sadness

D. insomnia

Answer: A

Rationale: Postpartum psychosis is at the severe end of the continuum of postpartum emotional

disorders. It is manifested by depression that escalates to delirium, hallucinations, anger toward

self and infant, bizarre behavior, mania, and thoughts of hurting herself and the infant. Feelings

of guilt, sadness, and insomnia are associated with postpartum depression.

14. A nurse is reviewing a journal article on the causes of postpartum hemorrhage. Which

condition would the nurse most likely find as the most common cause?

A. labor augmentation

B. uterine atony

C. cervical or vaginal lacerations

D. uterine inversion

Answer: B

Rationale: The most common cause of postpartum hemorrhage is uterine atony, failure of the

uterus to contract and retract after birth. The uterus must remain contracted after birth to control

bleeding from the placental site. Labor augmentation is a risk factor for postpartum hemorrhage.

Lacerations of the birth canal and uterine inversion may cause postpartum hemorrhage, but these

are not the most common cause.

15. A postpartum woman is diagnosed with endometritis. The nurse interprets this as an infection

involving which area? Select all that apply.

A. endometrium

B. decidua

C. myometrium

D. broad ligament

E. ovaries

F. fallopian tubes

Answer: A, B, C

Rationale: Endometritis is an infectious condition that involves the endometrium, decidua, and

adjacent myometrium of the uterus. Extension of endometritis can result in parametritis, which

involves the broad ligament and possibly the ovaries and fallopian tubes, or septic pelvic

thrombophlebitis.

16. A group of nurses are reviewing information about mastitis and its causes in an effort to

develop a teaching program on prevention for postpartum women. The nurses demonstrate

understanding of the information when they focus the teaching on ways to minimize risk of

exposure to which organism?

A. E. coli

B. S. aureus

C. Proteus

D. Klebsiella

Answer: B

Rationale: The most common infectious organism that causes mastitis is S. aureus, which comes

from the breast-feeding infant's mouth or throat. E. coli is another, less common cause. E. coli,

Proteus, and Klebsiella are common causes of urinary tract infections.

17. A home health care nurse is assessing a postpartum woman who was discharged 2 days ago.

The woman tells the nurse that she has a low-grade fever and feels "lousy." Which finding would

lead the nurse to suspect endometritis? Select all that apply.

A. lower abdominal tenderness

B. urgency

C. flank pain

D. breast tenderness

E. anorexia

Answer: A, E

Rationale: Manifestations of endometritis include lower abdominal tenderness or pain on one or

both sides, elevated temperature, foul-smelling lochia, anorexia, nausea, fatigue and lethargy,

leukocytosis, and elevated sedimentation rate. Urgency and flank pain would suggest a urinary

tract infection. Breast tenderness may be related to engorgement or suggest mastitis.

18. A postpartum client comes to the clinic for her routine 6-week visit. The nurse assesses the

client and suspects that she is experiencing subinvolution based on which finding?

A. nonpalpable fundus

B. moderate lochia serosa

C. bruising on arms and legs

D. fever

Answer: B

Rationale: Subinvolution is usually identified at the woman's postpartum examination 4 to 6

weeks after birth. The clinical picture includes a postpartum fundal height that is higher than

expected, with a boggy uterus; the lochia fails to change colors from red to serosa to alba within

a few weeks. Normally, at 4 to 6 weeks, lochia alba or no lochia would be present and the fundus

would not be palpable. Thus evidence of lochia serosa suggests subinvolution. Bruising would

suggest a coagulopathy. Fever would suggest an infection.

19. Assessment of a postpartum client reveals a firm uterus with bright-red bleeding and a

localized bluish bulging area just under the skin at the perineum. The woman also reports

significant pelvic pain and is experiencing problems with voiding. The nurse suspects which

condition?

A. hematoma

B. laceration

C. bladder distention

D. uterine atony

Answer: A

Rationale: The woman most likely has a hematoma based on the findings: firm uterus with

bright-red bleeding; localized bluish bulging area just under the skin surface in the perineal area;

severe perineal or pelvic pain; and difficulty voiding. A laceration would involve a firm uterus

with a steady stream or trickle of unclotted bright-red blood in the perineum. Bladder distention

would be palpable along with a soft, boggy uterus that deviates from the midline. Uterine atony

would be noted by a uncontracted uterus.

20. A postpartum woman is prescribed oxytocin to stimulate the uterus to contract. Which action

would be most important for the nurse to do?

A. Administer the drug as an IV bolus injection.

B. Give as a vaginal or rectal suppository.

C. Piggyback the IV infusion into a primary line.

D. Withhold the drug if the woman is hypertensive.

Answer: C

Rationale: When giving oxytocin, it should be diluted in a liter of IV solution and the infusion set

up to be piggy-backed into a primary line to ensure that the medication can be discontinued

readily if hyperstimulation or adverse effects occur. It should never be given as an IV bolus

injection. Oxytocin may be given if the woman is hypertensive. Oxytocin is not available as a

vaginal or rectal suppository.

21. Assessment of a postpartum woman experiencing postpartum hemorrhage reveals mild

shock. Which finding would the nurse expect to assess? Select all that apply.

A. diaphoresis

B. tachycardia

C. oliguria

D. cool extremities

E. confusion

Answer: A, D

Rationale: Signs and symptoms of mild shock include diaphoresis, increased capillary refill, cool

extremities, and maternal anxiety. Tachycardia and oliguria suggest moderate shock. Confusion

suggests severe shock.

22. A nurse is providing a refresher class for a group of postpartum nurses. The nurse reviews

the risk factors associated with postpartum hemorrhage. The group demonstrates understanding

of the information when they identify which risk factors associated with uterine tone? Select all

that apply.

A. rapid labor

B. retained blood clots

C. hydramnios

D. operative birth

E. fetal malpostion

Answer: A, C

Rationale: Risk factors associated with uterine tone include hydramnios, rapid or prolonged

labor, oxytocin use, maternal fever, or prolonged rupture of membranes. Retained blood clots are

a risk factor associated with tissue retained in the uterus. Fetal malposition and operative birth

are risk factors associated with trauma of the genital tract.

23. A nurse is massaging a postpartum client's fundus and places the nondominant hand on the

area above the symphysis pubis based on the understanding that this action:

A. determines that the procedure is effective.

B. helps support the lower uterine segment.

C. aids in expressing accumulated clots.

D. prevents uterine muscle fatigue.

Answer: B

Rationale: The nurse places the nondominant hand on the area above the symphysis pubis to help

support the lower uterine segment. The hand, usually the dominant hand that is placed on the

fundus, helps to determine uterine firmness (and thus the effectiveness of the massage).

Applying gentle downward pressure on the fundus helps to express clots. Overmassaging the

uterus leads to muscle fatigue.

24. A nurse is developing a plan of care for a woman who is at risk for thromboembolism. Which

measure would the nurse include as the most cost-effective method for prevention?

A. prophylactic heparin administration

B. compression stockings

C. early ambulation

D. warm compresses

Answer: C

Rationale: Although compression stockings and prophylactic heparin administration may be

appropriate, the most cost-effective preventive method is early ambulation. It is also the easiest

method. Warm compresses are used to treat superficial venous thrombosis.

25. A postpartum woman who developed deep vein thrombosis is being discharged on

anticoagulant therapy. After teaching the woman about this treatment, the nurse determines that

additional teaching is needed when the woman makes which statement?

A. "I will use a soft toothbrush to brush my teeth."

B. "I can take ibuprofen if I have any pain."

C. "I need to avoid drinking any alcohol."

D. "I will call my health care provider if my stools are black and tarry."

Answer: B

Rationale: Individuals receiving anticoagulant therapy need to avoid use of any over-the-counter

products containing aspirin or aspirin-like derivatives such as NSAIDs (ibuprofen) to reduce the

risk for bleeding. Using a soft toothbrush and avoiding alcohol are appropriate measures to

reduce the risk for bleeding. Black, tarry stools should be reported to the health care provider.

26. The nurse is developing a discharge teaching plan for a postpartum woman who has

developed a postpartum infection. Which measures would the nurse most likely include in this

teaching plan? Select all that apply.

A. taking the prescribed antibiotic until it is finished

B. checking temperature once a week

C. washing hands before and after perineal care

D. handling perineal pads by the edges

E. directing peribottle to flow from back to front

Answer: A, C, D

Rationale: Teaching should address taking the prescribed antibiotic until finished to ensure

complete eradication of the infection; checking temperature daily and notifying the practitioner if

it is above 100.4° F (38° C); washing hands thoroughly before and after eating, using the

bathroom, touching the perineal area, or providing newborn care; handling perineal pads by the

edges and avoiding touching the inner aspect of the pad that is against the body; and directing

peribottle so that it flows from front to back.

27. A nurse is assessing a postpartum client who is at home. Which statement by the client would

lead the nurse to suspect that the client may be developing postpartum depression?

A. "I just feel so overwhelmed and tired."

B. "I'm feeling so guilty and worthless lately."

C. "It's strange, one minute I'm happy, the next I'm sad."

D. "I keep hearing voices telling me to take my baby to the river."

Answer: B

Rationale: Indicators for postpartum depression include feelings related to restlessness,

worthlessness, guilt, hopeless, and sadness along with loss of enjoyment, low energy level, and

loss of libido. The statements about being overwhelmed and fatigued and changing moods

suggest postpartum blues. The statement about hearing voices suggests postpartum psychosis.

28. As part of an in-service program to a group of home health care nurses who care for

postpartum women, a nurse is describing postpartum depression. The nurse determines that the

teaching was successful when the group identifies that this condition becomes evident at which

time after birth of the newborn?

A. in the first week

B. within the first 2 weeks

C. in approximately 1 month

D. within the first 6 weeks

Answer: D

Rationale: PPD usually has a gradual onset and becomes evident within the first 6 weeks

postpartum. Postpartum blues typically manifests in the first week postpartum. Postpartum

psychosis usually appears about 3 months after birth of the newborn.

29. A nurse suspects that a client may be developing disseminated intravascular coagulation. The

woman has a history of placental abruption (abruptio placentae) during birth. Which finding

would help to support the nurse's suspicion?

A. severe uterine pain

B. board-like abdomen

C. appearance of petechiae

D. inversion of the uterus

Answer: C

Rationale: A complication of abruptio placentae is disseminated intravascular coagulation (DIC),

which is manifested by petechiae, ecchymoses, and other signs of impaired clotting. Severe

uterine pain, a board-like abdomen, and uterine inversion are not associated with DIC and

placental abruption.

30. On a follow-up visit to the clinic, a nurse suspects that a postpartum client is experiencing

postpartum psychosis. Which finding would most likely lead the nurse to suspect this condition?

A. delusional beliefs

B. feelings of anxiety

C. sadness

D. insomnia

Answer: A

Rationale: Postpartum psychosis is at the severe end of the continuum of postpartum emotional

disorders. It is manifested by depression that escalates to delirium, hallucinations, delusional

beliefs, anger toward self and infant, bizarre behavior, mania, and thoughts of hurting herself and

the infant. Feelings of anxiety, sadness, and insomnia are associated with postpartum depression.

31. A nurse is assessing a client who gave birth vaginally about 4 hours ago. The client tells the

nurse that she changed her perineal pad about an hour ago. On inspection, the nurse notes that

the pad is now saturated. The uterus is firm and approximately at the level of the umbilicus.

Further inspection of the perineum reveals an area, bluish in color and bulging just under the skin

surface. Which action would the nurse do next?

A. Apply warm soaks to the area.

B. Notify the health care provider.

C. Massage the uterine fundus.

D. Encourage the client to void.

Answer: B

Rationale: The client is experiencing postpartum hemorrhage secondary to a perineal hematoma.

The nurse needs to notify the health care provider about these findings to prevent further

hemorrhage. Applying warm soaks to the area would do nothing to control the bleeding. With a

perineal hematoma, the uterus is firm, so massaging the uterus or encouraging the client to void

would not be appropriate.

32. A nurse is providing education to a woman who is experiencing postpartum hemorrhage and

is to receive a uterotonic agent. The nurse determines that additional teaching is needed when the

woman identifies which drug as possibly being prescribed as treatment?

A. oxytocin

B. methylergonovine

C. carboprost

D. magnesium sulfate

Answer: D

Rationale: Magnesium sulfate is during labor as a tocolytic agent to slow or halt preterm labor. It

is not be used to treat postpartum hemorrhage. Oxytocin, methylergonovine, and carboprost are

drugs used to manage postpartum hemorrhage.