01. A nurse on the postpartum unit is caring for a client following a cesarean birth. Which of the

following assessments is the nurse's priority?

Amount of lochia

When using the airway, breathing, circulation approach to client care, the nurse should place the

priority in the immediate postpartum period on assessing the amount of postpartum lochia.

The greatest risk to the client is bleeding and postpartum hemorrhage.

02. A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior

position. The client is dilated to 8 cm and reports back pain. Which of the following actions

should the nurse take?

Apply sacral counterpressure

The nurse should apply sacral counterpressure to assist in relieving back labor pain related to

fetal posterior position.

03. A nurse is demonstrating to a client how to bathe her newborn. In which order should the

nurse perform the following actions? (Move the steps into the box on the right, placing them in

the selected order of performance. Use all the steps.)

Wipe the newborn’s eyes from the inner canthus outward.

Wash the newborn’s neck by lifting the newborn’s chin.

Cleanse the skin around the newborn’s umbilical cord stump.

Wash the newborn’s legs and feet.

Clean the newborn’s diaper area.

The nurse should demonstrate how to bathe a newborn by using a head to toe, clean to dirty,

approach. Therefore, the nurse should first wipe the newborn's eyes from the inner canthus

outward using plain water. The nurse should then wash the newborn's neck by lifting the

newborn's chin. Next, the nurse should cleanse the skin around the umbilical cord stump

followed by washing the newborn's legs and feet. The last step of the bath should be to clean the

newborn's diaper area.

04. A nurse is caring for a client and her partner who have experienced a fetal death. Which of

the following actions should the nurse take?

Take photos of the newborn to give to the parents.

The nurse should create a memory box that includes mementos of the newborn (for example,

photos, the newborn's ID bands, the newborn's hat, and the newborn's blanket).