Chapter 14: Nursing Care of the Family during the Fourth Trimester

Chapter 14: Nursing Care of the Family during the Fourth Trimester

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. A 25-year-old gravida 2, para 2-0-0-2 gave birth 4 hours ago to a 9-pound, 7-ounce boy after augmentation of labor with Pitocin. She puts on her call light and asks for her nurse right away, stating, “I’m bleeding a lot.” The most likely cause of postpartum hemorrhage in this woman is:

a.	Retained placental fragments.
b.	Unrepaired vaginal lacerations.
c.	Uterine atony.
d.	Puerperal infection.

 

ANS: C

 

	Feedback
A	Although retained placental fragments may cause postpartum hemorrhage, this typically would be detected in the first hour after delivery of the placenta and is not the most likely cause of hemorrhage in this woman.
B	Although unrepaired vaginal lacerations may cause bleeding, they typically would occur in the period immediately after birth.
C	This woman gave birth to a macrosomic boy after Pitocin augmentation. The most likely cause of bleeding 4 hours after delivery, combined with these risk factors, is uterine atony.
D	Puerperal infection can cause subinvolution and subsequent bleeding, but it typically would be detected 24 hours after delivery.

 

DIF:   Cognitive Level: Analysis             REF:  397

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Assessment

 

2. On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse’s first action is to:

a.	Begin an intravenous (IV) infusion of Ringer’s lactate solution.
b.	Assess the woman’s vital signs.
c.	Call the woman’s primary health care provider.
d.	Massage the woman’s fundus.

 

ANS: D

 

 

	Feedback
A	The nurse may begin an IV infusion to restore circulatory volume, but this would not be the first action.
B	Blood pressure is not a reliable indicator of impending shock from impending hemorrhage; assessing vital signs should not be the nurse’s first action.
C	The physician would be notified after the nurse completes the assessment of the woman.
D	The nurse should assess the uterus for atony. Uterine tone must be established to prevent excessive blood loss.

 

DIF:   Cognitive Level: Application        REF:  399

OBJ:  Client Needs: Health Promotion and Maintenance

TOP:  Nursing Process: Implementation

 

3. A woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener. What information is most closely correlated with these orders?

a.	The woman is a gravida 2, para 2.
b.	The woman had a vacuum-assisted birth.
c.	The woman received epidural anesthesia.
d.	The woman has an episiotomy.

 

ANS: D

 

	Feedback
A	A multiparous classification is not an indication for these orders.
B	A vacuum-assisted birth may be used in conjunction with an episiotomy, which would indicate these interventions.
C	Use of epidural anesthesia has no correlation with these orders.
D	These orders are typical interventions for a woman who has had an episiotomy, lacerations, and hemorrhoids.

 

DIF:   Cognitive Level: Comprehension  REF:  400

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Planning

 

4. The laboratory results for a postpartum woman are as follows: blood type, A; Rh status, positive; rubella titer, 1:8 (EIA 0.8); hematocrit, 30%. How would the nurse best interpret these data?

a.	Rubella vaccine should be given.
b.	A blood transfusion is necessary.
c.	Rh immune globulin is necessary within 72 hours of birth.
d.	A Kleihauer-Betke test should be performed.

 

ANS: A

 

	Feedback
A	This patient’s rubella titer indicates that she is not immune and that she needs to receive a vaccine.
B	These data do not indicate that the patient needs a blood transfusion.
C	Rh immune globulin is indicated only if the patient has a negative Rh status and the infant has a positive Rh status.
D	A Kleihauer-Betke test should be performed if a large fetomaternal transfusion is suspected, especially if the mother is Rh negative. The data do not provide any indication for performing this test.

 

DIF:   Cognitive Level: Comprehension  REF:  406

OBJ:    Client Needs: Health Promotion and Maintenance    TOP:    Nursing Process: Planning