Signs & Symptoms
A postpartum patient reports severe perineal pain unrelieved by analgesics and has a firm uterus with moderate vaginal bleeding. What condition should the nurse suspect?
A- Uterine atony
B- Vaginal hematoma
C- Endometritis
D- Retained placenta
B- Vaginal hematoma
Rationale- uterine atony would present with a bogy uterus, not firm. Endometritis would present abnormal bleeding or discharge. Retained placenta would present with heavy bleeding.
A client in labor is prescribed oxytocin. What is the priority nursing action while this medication is being administered?
A- Monitor maternal blood glucose
B- Monitor fetal heart rate and uterine contractions
C- Administer magnesium sulfate concurrently
D- Assess maternal temperature hourly
B- Monitor fetal heart rate and uterine contractions
Rationale- Oxytocin causes uterine hyper stimulation and fetal distress therefore continuous monitoring is essential
The priority intervention for a postpartum patient with a boggy uterus and heavy lochia is to:
A- Call the provider
B- Massage the fundus
C- Insert a Foley catheter
D- Start IV fluids
B- Massage the fundus
Rationale: A boggy uterus suggests uterine agony therefore a fundal massage would promote contraction and reduce bleeding
A neonates bilirubin level is 18 at 48 hours of age and remains elevated for 2 weeks. This result indicates:
A- Physiological jaundice
B- Breastfeeding jaundice
C- Pathological jaundice
D- Normal adaptation
C- pathological jaundice
Rationale: Bilirubin > 15 before 72 hours is abnormal and suggest pathological jaundice.
Pathological jaundice is more severe and persistent than normal physiological jaundice. It appears within the first 24 hours of life and persists beyond the normal 1-2 weeks time frame.
Physiological jaundice is normal and usually manifests within the first 24 hours of life, begins to peak around 2-4 days, and begins to resolve around 1-2 weeks.
Breastfeeding jaundice usually occurs in the first week of life as a result of not receiving adequate milk as breastfeeding is being established.
Normal adaptation jaundice usually occurs within 2-4 days after birth and resolves around 1-2 weeks after the liver matures.
The nurse is caring for a client in active labor who is receiving epidural anesthesia. Which of the following is the nurse’s priority?
A- Monitor fetal heart tones a 1 hr
B- Assess for maternal hypotension
C- Provide oral hydration
D- Encourage frequent ambulation
B- Assess for maternal hypotension
Rationale: Epidurals can cause vasodilation and hypotension leading to fetal distress
A newborn in the NICU is experiencing grunting, nasal flaring, and intercostal retractions. These signs are most indicative of:
A- Normal transition to extrauterine life
B- Respiratory distress syndrome
C- Neonatal hypoglycemia
D- Meconium aspiration syndrome
B- Respiratory Distress syndrome
Which of the following is commonly administered to newborns within the first hour after birth to promote blood clotting?
A- Erythromycin ophthalmic ointment
B- Hepatitis B vaccine
C- phytonadione
D- Ampicillin
C- phytonadione (Vitamin K)
Rationale: Newborns naturally have low Vitamin K which is necessary for clotting
A newborn with mild respiratory distress is placed in a radiant warmer. What additional intervention helps maintain respiratory function?
A- Place infant in prone position
B- Perform vigorous suctioning
C- Ensure the head is in sniffing position
D- Delay cord clamping
C- Ensure the head is in sniffing position
Rationale: Proper head positioning maintains airway patency in neonates
Which maternal lab value during labor requires immediate attention?
A- WBC 13,000
B- Hct 32%
C- Platelets 80,000
D- Hgb 11.2
Rationale: Platelet count <100,000 can increase bleeding risk and may contraindicate anesthesia
A postpartum client is breastfeeding and complains of cracked nipples. What is the best nursing intervention?
A- Advise her to stop breastfeeding temporarily
B- Teach proper latch technique
C- Apply powder to nipples
D- Limit feeding to 5 minutes per side
B- Teach proper latch technique
Rationale: Poor latch is a common cause of nipple trauma. Education improved feeding and prevents damage.
Which symptom in a laboring client should be reported immediately?
A- Bloody show
B- Back pain
C- Sudden cessation of contractions
D- Persistent late decelerations
D- Persistent late decelerations
Rationale: Late deceleration indicate uterplacental insufficiency and fetal hypoxia
A postpartum patient received methylergonovine. What vital signs should the nurse closely monitor?
A- HR
B- RR
C- BP
D- Temp
Rationale: Methylergonovine is used to prevent and control postpartum hemorrhage. Can cause HTN and is contraindicated in hypertensive patients.
During the 3rd stage of labor, the nurse notices excessive bleeding. What should be the initial action?
A- Document findings
B- Increase oxytocin infusion
C- Notify the provider
D- Perform uterine massage
D- Perform uterine massage
Rationale: Third stage of labor is the final stage of labor after the baby is born when the placenta is delivered. Initial intervention for excessive bleeding after delivery is uterine massage to promote contraction.
A newborns glucose level is 30. What should the nurse do first?
A- Notify the physician
B- Recheck the glucose level in 2 hours
C- Feed the baby breast milk or formula
D- Document and continue to monitor
C- Feed the baby breast milk or formula
Rationale: Prompt feeding is the first line of intervention.
A client delivers a baby with an APGAR score of 4 at 1 minute and 6 at 5 minutes. What is the nurses next action?
A- Continue routine care
B- Call a code blue
C- Initiate resuscitation efforts
D- Monitor closely and provide supportive care
D- Monitor closely and provide supportive care
Rationale: An APGAR score of 6 at 5 minutes warrants observation and possible interventions but not necessarily a code blue unless deterioration occurs
Which of the following is a common sign of neonatal hypoglycemia?
A- Jitteriness
B- Bradycardia
C- Diaphoresis
D- Excessive weight gain
A- Jitteriness
A neonate in the NICU is prescribed ampicillin IV. What is the most important nursing action before administering?
A- Assess bilirubin levels
B- Check the infants blood glucose
C- Verify correct weight for dosing
D- Measure head circumference
C- Verify correct weight for dosing
Rationale: Neonate medications are highly weight based therefore weights should be verified before administering.
Which nursing intervention helps prevent infection in the newborn nursery?
A- Keeping bassinets 3 inches apart
B- Wearing gloves when handling newborns
C- Administering antibiotics prophylactically
D- Allowing open visitation
B- Wearing gloves when handling newborns
Rationale: Glove use is a standard infection control practice in nurseries.
A postpartum woman has a WBC of 22,000 on day 1. What is the correct interpretation?
A- Normal postpartum finding
B- Indicates severe infection
C- Hematologic disorder
D- Isolation precautions
A- normal postpartum finding
Rationale: WBC can rise to 20,000-25,000 postpartum without presence of infection.
Which action by the nurse best reduced the risk of postpartum hemorrhage?
A- Encourage early breastfeeding
B- Keep mother NPO
C- Administer antibiotics prophylactically
D- Delay ambulation
A- Encourage early breastfeeding
Rationale: Breastfeeding stimulates oxytocin release which contracts the uterus and helps prevent hemorrhage
A- Fever
B- Found smelling lochia
C- Chills
D- Hypertension
E- Uterine tenderness
Answer: A, B, C, & E
Rationale- All signs of endometritis. Hypertension is unrelated.
Which of the following are potential side effects of magnesium sulfate therapy in a preeclampsia patient? Select All That Apply
A- Respiratory depression
B- Decreased deep tendon reflexes
C- Increased uterine output
D- Flushing
E- Hypotension
Answer- A, B, D, & E
Rationale: Magensium can cause respiratory depression, decreased DTR’s, flushing, and hypotension. Increased urine output is not a side effect.
Which nursing action is appropriate when caring for a newborn receiving phototherapy? Select All That Apply
A- Monitor temperature frequently
B- Turn off lights during feedings
C- Keep infant fully clothed under lights
D- Reposition every 2 hours
E- Encourage frequent feedings
F- Cover eyes and genital area
Answer- A, B, D, E, & F
Rationale: All are correct except keeping infant fully clothed- we want to expose the skin so the phototherapy light is effective.
Which of the following newborn lab values would be considered abnormal and require follow-up? Select All That Apply
A- Glucose 28
B- Bilirubin 19
C- Hct 60%
D- WBC 24,000
E- Platelet 75,000
Answer- A, B, & E
Rationale: Hypoglycemia, pathological jaundice, and thrombocytopenia
The nurse is teaching a postpartum client about warning signs to report after discharge. Which of the following should the nurse include? Select All That Apply
A- Saturating a peripad in 15 minutes
B- Temp > 100.4 F (38 C)
C- Persistent headache unrelieved by acetaminophen
D- Engorgement of breasts on day 3
E- Foul smelling vaginal discharge
Answer: A, B, C, & E
Rationale- All are danger signs. Breast engorgement is normal on day 3-5.