Review Questions for the NCLEX® Examination

• A primigravida has delivered a baby vaginally after 6 hours of labor. She had an uneventful pregnancy and is in good general health. She is transferred from the recovery room to the postpartum unit. What interventions are included in routine postpartum care? (Select all that apply.)
• • 1. Assessment of intake and output until the patient is voiding in sufficient quantities
  • 2. Insertion of a catheter to assess residual urine after the initial voiding
  • 3. Firm massage of the fundus every 15 minutes
  • 4. Assessment of the emotional status of the new mother
  • 5. Checking of breasts for engorgement and cracking of nipples
• The nurse is performing a routine postpartum assessment. Which action is indicated before the fundal height is measured?
  • 1. Massage the uterus.
  • 2. Apply pressure to the fundus to check for clots.
  • 3. Elevate the head of the bed.
  • 4. Ask the patient to empty her bladder.
• The nurse finds bright red bleeding on a patient’s peripad. The stain is about 6 inches long. What is the correct description of the character and amount of lochia?
  • 1. Lochia rubra, moderate
  • 2. Lochia serosa, heavy
  • 3. Lochia rubra, heavy
  • 4. Lochia serosa, light
• The nurse is teaching breast care for the lactating woman. What information should be included? (Select all that apply.)
  • 1. Expose the nipples to air for 20 to 30 minutes daily.
  • 2. Wear a supportive bra 24 hours a day for the first few weeks.
  • 3. Wash breasts and nipples with soap and water before each feeding.
  • 4. Use plastic liners in bras.
  • 5. Use ice packs every 4 hours as needed for discomfort associated with engorgement.
• A woman asks the nurse how she will know her baby is getting enough milk. The nurse’s response is based on understanding that which is the best determinant?
  • 1. The baby awakens every 4 to 6 hours to eat.
  • 2. The baby stops nursing when full.
  • 3. The baby has 6 to 10 wet diapers per day.
  • 4. The baby cries when hungry.
• In evaluating maternal adjustment, which behavior leads the nurse to believe that the patient is still in the taking-in phase?
  • 1. The mother states she is “starving” and can’t wait to eat.
  • 2. The majority of the mother’s time is spent talking about her delivery experience.
  • 3. The mother takes a shower and washes her hair.
  • 4. The mother asks the nurse to teach her how to give her baby a bath.
• A baby boy is 1 hour old when admitted to the newborn nursery. He weighs 7 lb, 3 oz; is 21 inches long; has irregular respirations of 42 breaths/min with adequate chest movement, a heart rate of 145 bpm, and a temperature of 35.6° C, axillary; and is acrocyanotic. What is an appropriate goal for this baby within the next 2 hours, based on these findings?
  • 1. Color will remain unchanged.
  • 2. Respirations will slow.
  • 3. Temperature will stabilize at 36.5° to 37° C.
  • 4. Heart rate will decrease to 100 bpm.
• When teaching parents how to bathe their baby, which point should the nurse stress?
  • 1. Avoid immersing the baby in water until after the umbilical cord has fallen off.
  • 2. Use only mild medicated or scented soap.
  • 3. Apply baby powder after the bath to keep the skin dry.
  • 4. Apply baby oil after the bath to keep the skin soft and smooth.
• When providing education to parents about care of the umbilical cord, what information should be included? (Select all that apply.)
  • 1. Cleaning the cord with an alcohol swab
  • 2. Keeping the diaper folded below the cord
  • 3. Applying triple dye to the cord
  • 4. Keeping the cord moist to promote healing
  • 5. Oiling the cord to facilitate it falling off
• A baby has a Gomco circumcision. What instruction should the nurse give his parents for care of the circumcised penis?
  • 1. Soak the penis in warm water daily.
  • 2. Cover the glans with a petroleum gauze dressing.
  • 3. Clean the glans with alcohol to promote healing.
  • 4. Remove any yellowish exudate that forms within 24 hours.
• On examining a woman who gave birth 5 hours previously, the nurse finds that the woman has saturated a perineal pad within 15 minutes. What action is the nurse’s first priority?
  • 1. Increase the drip rate of an IV infusion of Ringer lactate solution.
  • 2. Assess the patient’s vital signs.
  • 3. Call the patient’s primary health care provider.
  • 4. Palpate the woman’s fundus.
• A woman gave birth 48 hours ago to a healthy baby girl. She has decided to bottle feed. During the assessment, the nurse notices that both breasts are swollen, warm, and tender on palpation. The patient should be advised that this is best treated with which action?
  • 1. Running warm water over her breasts during a shower
  • 2. Applying ice to the breasts for comfort
  • 3. Expressing small amounts of milk from the breasts to relieve pressure
  • 4. Wearing a loose-fitting bra to prevent nipple irritation
• A first-time mother is to be discharged from the hospital tomorrow with her baby girl. Which maternal behavior indicates a need for further intervention by the nurse before she can be discharged?
  • 1. The mother leaves the baby on her bed while she takes a shower.
  • 2. The mother continues to hold and cuddle her baby after she has fed her.
  • 3. The mother reads a magazine while her baby sleeps.
  • 4. The mother changes her baby’s diaper, then shows the nurse the contents of the diaper.
• The nurse observes several interactions between a postpartum woman and her new son. Which behavior, if exhibited by this woman, does the nurse identify as maladaptive regarding parent-infant attachment?
  • 1. The mother talks and coos to her son.
  • 2. The mother seldom makes eye contact with her son.
  • 3. The mother cuddles her son close to her.
  • 4. The mother tells visitors how well her son is feeding.
•  The nurse can help a father in his transition to parenthood with what action?
  • 1. Pointing out that the infant turned to his voice
  • 2. Encouraging him to go home to get some sleep
  • 3. Taping the baby’s diaper a different way
  • 4. Suggesting that he let the baby sleep in the bassinet
• When performing a postpartum assessment, what should the nurse do?
  • 1. Assist the patient into a lateral position with upper leg flexed forward to facilitate examination of her perineum.
  • 2. Assist the patient into a supine position with her arms above her head and her legs extended for the examination of her abdomen.
  • 3. Instruct the patient to avoid urinating just before the examination because a full bladder facilitates funda position.
  • 4. Wash hands and put on sterile gloves before beginning.
• The nurse helps the breastfeeding woman change her newborn’s diaper after the baby’s first bowel movement. The mother expresses concern because of a large amount of sticky, dark green—almost black—stool. She asks the nurse if something is wrong. What information should be included in the nurse’s response?
  • 1. Tell the woman not to worry because all breastfed babies have this type of stool.
  • 2. Explain that this type of stool is called meconium and is expected for the first few bowel movements of all newborns.
  • 3. Ask the woman what she ate at her last meal before giving birth.
  • 4. Suggest that the mother ask her pediatrician to explain newborn stool patterns.

Fill in the Blank

•  _________ refers to the process whereby an infant’s behavior and characteristics call forth a corresponding set of maternal behaviors and characteristics.
•  _________ refers to the face-to-face position in which a parent’s and infant’s faces are approximately 20 cm apart and on the same plane or level.
•  _________ is a term applied to a parent’s absorption, preoccupation, and interest in his or her infant; the term typically is used to describe the father’s intense involvement with his newborn.
• 21. _________ is the phase of maternal postpartum adjustment characterized by a woman’s need to review her labor and birth experiences with the nurse who cared for her while she was in labor. Other behaviors exhibited include reliance on others to help her meet needs, excitement, and talkativeness.