Page 803 - Saunders Comprehensive Review For NCLEX-RN

2. Rest during the acute phase.
3. Maintain a fluid intake of at least 3000 mL/day.

4. Continue to breast-feed if the breasts are not too sore.

5. Take the prescribed antibiotics until the soreness subsides.

6. Avoid decompression of the breasts by breast-feeding or

breast pump.
260. The nurse is providing instructions about measures to prevent postpartum
mastitis to a client who is breast-feeding her newborn. Which client
statement would indicate a need for further instruction?
1. “I should breast-feed every 2 to 3 hours.”
2. “I should change the breast pads frequently.”
3. “I should wash my hands well before breast- feeding.”
4. “I should wash my nipples daily with soap and water.”
261. The postpartum nurse is assessing a client who delivered a healthy infant by
cesarean section for signs and symptoms of superficial venous thrombosis.
Which sign should the nurse note if superficial venous thrombosis were
present?
1. Paleness of the calf area
2. Coolness of the calf area
3. Enlarged, hardened veins
4. Palpable dorsalis pedis pulses
262. A client in a postpartum unit complains of sudden sharp chest pain and
dyspnea. The nurse notes that the client is tachycardic and the respiratory
rate is elevated. The nurse suspects a pulmonary embolism. Which should be
the initial nursing action?
1. Initiate an intravenous line.
2. Assess the client’s blood pressure.
3. Prepare to administer morphine sulfate.
4. Administer oxygen, 8 to 10 L/minute, by face mask.
263. The nurse is assessing a client in the fourth stage of labor and notes that the
fundus is firm, but that bleeding is excessive. Which should be the initial
nursing action?
1. Record the findings.
2. Massage the fundus.
3. Notify the obstetrician (OB).
4. Place the client in Trendelenburg’s position.
264. The nurse is preparing to care for four assigned clients. Which client is at
most risk for hemorrhage?
1. A primiparous client who delivered 4 hours ago
2. A multiparous client who delivered 6 hours ago
3. A multiparous client who delivered a large baby after oxytocin
induction
4. A primiparous client who delivered 6 hours ago and had epidural
anesthesia
265. A postpartum client is diagnosed with cystitis. The nurse should plan for

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