CH 28

A patient who has had a routine vaginal delivery has a urinary output of 100 mL, 150 mL, and 275 mL recorded for three voidings. Which nursing action would be best? 1 Collect a urine specimen. 2 Massage the uterine fundus. 3 Catheterize the patient, if ordered. 4 Perform perineal care to promote bladder emptying.

3 Catheterize the patient, if ordered.

Which instructions would the nurse give to the patient regarding taking Simethicone (Mylicon)? 1 Swallow the capsule whole. 2 Crush the tablet into powder form. 3 Chew the pill thoroughly before swallowing. 4 Allow the tablet to dissolve under the tongue.

3 Chew the pill thoroughly before swallowing.

A patient has a pulse rate of 120 beats/min and a 60/48 mm Hg blood pressure, and the skin is cool and clammy. Which interventions would the nurse institute? Select all that apply. 1 Prescribe Pitocin. 2 Administer blood. 3 Massage the fundus. 4 Elevate the legs to 30 degrees. 5 Give oxygen, if prescribed. 6 Maintain intravenous (IV) fluids.

3 Massage the fundus. 4 Elevate the legs to 30 degrees. 5 Give oxygen, if prescribed. 6 Maintain intravenous (IV) fluids.

A labor and delivery nurse explains perineal care to a patient after delivery. Which action by the patient indicates a need for further teaching? 1 Wiping the perineal area from front to back 2 Spraying the perineal area with water after voiding 3 Vigorously wiping the perineal area after urinating 4 Changing the perineal pad after voiding and when soiled

3 Vigorously wiping the perineal area after urinating

The nurse finds that the glucose level in a neonate is 45 mg/dL and advises the parents to avoid giving glucose supplements to the neonate before breast-feeding. Why does the nurse give this advice to the parents? 1 To ensure that the neonate takes interest in breast-feeding 2 To ensure that the neonate has optimal blood glucose levels 3 To ensure that the neonate maintains normal voiding pattern 4 To ensure that the neonate has an optimal body temperature

1 To ensure that the neonate takes interest in breast-feeding

While caring for a lactating patient, the nurse suggests that the patient place the infant on her shoulder after feeding. Which reason for this suggestion is best? 1 To promote burping in the infant 2 To encourage regurgitation of milk 3 To prevent constipation in the infant 4 To retract excess milk from the infant

1 To promote burping in the infant

A nursery nurse has given instruction to a new mother about cord care. Which statement would warrant a review of cord care after discharge? 1 "The cord will come off within 10 days." 2 "I must place the cord under the diaper." 3 "I will not place the baby in water until the cord comes off." 4 "Alcohol should be placed on the cord with diaper changes."

2 "I must place the cord under the diaper."

Which statement indicates that a mother fully understands care of her son's penis after circumcision? Select all that apply. 1 "I must apply the diaper extra snugly to control the bleeding." 2 "I will try not to touch the penis too much because it will be painful to the baby." 3 "I should put petroleum jelly on the penis with each diaper change." 4 "Some yellow discharge may be seen on the penis after a few days." 5 "I will clean the penis with warm water once a day"

2 "I will try not to touch the penis too much because it will be painful to the baby." 3 "I should put petroleum jelly on the penis with each diaper change." 4 "Some yellow discharge may be seen on the penis after a few days."

Which question by a patient would warrant additional teaching regarding breast-feeding and home care to a new mother? 1 "Is cabbage one of the foods I should avoid?" 2 "Should I wait a week before beginning my diet?" 3 "If I add additional calories, will my baby get the needed nutrients?" 4 "I am out of vitamins; can you have a prescription called to my pharmacy?"

2 "Should I wait a week before beginning my diet?"

Which instructions would the nurse give to a new mother regarding umbilical cord care? 1 "Apply alcohol on the cord stump daily to keep it dry until it falls off." 2 "Apply Vaseline to the cord stump several times a day to keep it moist until it comes off." 3 "Gently manipulate the cord stump side to side until it loosens and can be easily removed." 4 "Place the infant in warm bathwater to help the cord stump to soak off over the next 7 to 10 days."

1 "Apply alcohol on the cord stump daily to keep it dry until it falls off."

When would a nurse recommend that a mother give her newborn 15 mL of water? 1 When the baby regurgitates 2 Before giving formula 3 Before breast-feeding 4 After the baby drinks cow's milk

2 Before giving formula

During palpation, the nurse finds that a 10-week postpartum patient's uterus is involuted. Which finding regarding the uterine fundus enabled the nurse to reach this conclusion? 1 Distended 2 No longer palpable 3 At the level of the umbilicus midline 4 Between the umbilicus and the symphysis pubis

2 No longer palpable

Which intervention should the nurse provide to the non-breastfeeding postpartum patient to provide relief from swollen, firm, and painful breasts? Select all that apply. 1 Instruct the patient to restrict fluids. 2 Suggest the patient take lukewarm showers. 3 Instruct the patient to avoid consuming dairy. 4 Suggest the patient wear a good, supportive bra. 5 Apply ice bags on the patient's breasts four times daily.

2 Suggest the patient take lukewarm showers. 4 Suggest the patient wear a good, supportive bra. 5 Apply ice bags on the patient's breasts four times daily.

The nurse is teaching about elimination patterns in an infant to the student nurse. Which statement made by the student nurse indicates the need for additional teaching? 1 "The process of defecation commonly causes strain in infants." 2 "Formula-fed babies have thicker stools compared with breast-fed infants." 3 "Green-colored watery stools are observed for 3 weeks after birth in infants." 4 "Frequency of passing stools in breast-fed infants is more than in bottle-fed infants."

3 "Green-colored watery stools are observed for 3 weeks after birth in infants."

An Rh-negative patient gives birth to an Rh-positive baby. Which essential intervention should the nurse perform? 1 Administer the rubella vaccine. 2 Prepare for a blood transfusion. 3 Administer RhoGAM as prescribed. 4 Give the infant a vitamin K injection.

3 Administer RhoGAM as prescribed.

Which behavior by a new breast-feeding mother would call for immediate corrective action? 1 Burping the infant after 15 minutes of feeding 2 Holding the breast away from the infant's nostrils 3 Swiftly removing the breast from the infant's mouth 4 Allowing the infant to feed on both breasts, as needed

3 Swiftly removing the breast from the infant's mouth

A postpartum nurse is rounding on a patient 3 hours after vaginal delivery. Which statement by the patient would be of concern to the nurse? 1 "This is the most beautiful baby in the world." 2 "I can't wait to dress the baby in a blue outfit." 3 "The baby must be hungry; he is breast-feeding well." 4 "What a disappointment; I thought I was having a girl."

4 "What a disappointment; I thought I was having a girl."

Which signs and symptoms would indicate to the nurse that a newly postpartum patient may be in shock? Select all that apply. 1 Weakness 2 Warm skin 3 Tachycardia 4 Gray skin tone 5 Increased blood pressure

1 Weakness 3 Tachycardia 4 Gray skin tone

The nurse palpates the uterus of a postpartum patient for involution and observes that the uterine fundus is soft and distended. Which medication does the nurse expect the health care provider to prescribe to the patient? 1 Nystatin (Mycostatin) 2 Simethicone (Mylicon) 3 Benzocaine (Dermoplast ointment) 4 Methylergonovine maleate (Methergine)

4 Methylergonovine maleate (Methergine)

A nurse is discharging a newborn infant. For which symptoms would the parents need to call the health care provider? Select all that apply. 1 Gas 2 Fever 3 Diarrhea 4 Vomiting 5 Spitting up

2 Fever 3 Diarrhea 4 Vomiting

Which reflex is being demonstrated when the newborn curls the toes downward? 1 Moro's 2 Stepping 3 Palmar grasp 4 Planter grasp

4 Planter grasp

Which condition would be a contraindication to the patient taking ibuprofen (Motrin) for incisional pain? 1 Arthritis 2 Migraines 3 Pancreatitis 4 Kidney failure

4 Kidney failure

Which physical signs and symptoms might the postpartum patient experience following delivery? Select all that apply. 1 A normal bowel movement within 2 to 3 days 2 Increased diaphoresis, most commonly at night 3 A low-grade fever the first 48 hours after delivery 4 Increased urination beginning 4 to 6 hours after delivery 5 Bright red vaginal drainage that will saturate one pad every 15 minutes

1 A normal bowel movement within 2 to 3 days 2 Increased diaphoresis, most commonly at night 4 Increased urination beginning 4 to 6 hours after delivery

Which nursing concerns are most appropriate for a breast-feeding mother? Select all that apply. 1 Anxiety related to lactation expectations 2 Decreased caloric intake because of lactation needs 3 Potential for infection related to dry, cracked nipples 4 Potential for dehydration because of fluid requirements 5 Potential for constipation because of fluid requirements

1 Anxiety related to lactation expectations 2 Decreased caloric intake because of lactation needs 3 Potential for infection related to dry, cracked nipples

Which reason would the nurse give to the mother of a newborn on why not to feed the infant cow's milk? 1 Causes nausea and skin rashes 2 Increases glucose level to 45 mg/dL 3 Impairs swallowing reflex 4 Causes constipation from cow's milk

1 Causes nausea and skin rashes

The nurse would primarily monitor for symptoms of which conditions in the neonate after administering 1 mg of vitamin K (AquaMEPHYTON) intramuscularly? Select all that apply. 1 Kernicterus 2 Constipation 3 Hypothermia 4 Hyperbilirubinemia 5 Hemolytic anemia

1 Kernicterus 4 Hyperbilirubinemia 5 Hemolytic anemia

Which interventions should the nurse perform to provide effective care to a newly postpartum patient that reports feeling weak and "seeing stars"? Select all that apply. 1 Monitor the patient's vital signs. 2 Gently massage the patient's uterus. 3 Make the patient lie flat on the back. 4 Notify to the health care provider. 5 Discontinue the administration of saline solution.

1 Monitor the patient's vital signs. 2 Gently massage the patient's uterus. 4 Notify to the health care provider.

A patient with hyperglycemia had a preterm delivery. Which intervention would the nurse most likely plan to prevent complications in the newborn? 1 Administer bovine milk to the newborn within 2 hours of birth. 2 Administer glucose solution to the newborn 1 hour after birth. 3 Administer 15 mL of sterile water before the newborn is breast-fed. 4 Administer insulin as per health care provider's instructions.

2 Administer glucose solution to the newborn 1 hour after birth.

A patient reports pain in her right calf, and the licensed practical/vocational nurse (LPN/LVN) notes the area is reddened and edematous. Which intervention should the nurse perform next? 1 Report the findings to the registered nurse (RN). 2 Assess for a positive or negative Homans' sign. 3 Gently massage the area to improve circulation. 4 Place a warm, moist compress to the area and offer an analgesic on an as-needed (PRN) basis.

2 Assess for a positive or negative Homans' sign.

The nurse administers the rubella vaccine to a recently delivered mother shortly before discharge. Which essential information would the nurse include as part of the teaching process? 1 A consent form will need to be signed. 2 Avoid conceiving for at least 3 months. 3 The medication is known to cause a rash. 4 The injection may cause some discomfort.

2 Avoid conceiving for at least 3 months.

Which physiologic adaptations does the nurse expect to occur in the newly postpartum patient? Select all that apply. 1 Increase in appetite 2 Bruising of the perineum 3 Sloughing of the uterine lining 4 Rapid decline of cardiac output 5 Immediate descent of the uterus

2 Bruising of the perineum 3 Sloughing of the uterine lining 4 Rapid decline of cardiac output

For which reason would a lactating mother lightly brush the infant's lips with the nipple? 1 To break the milk suction 2 To promote rooting reflex 3 To reduce pain while feeding 4 To prevent aspiration of the milk

2 To promote rooting reflex

For which reason would the nurse administer vitamin K (AquaMEPHYTON) intramuscularly to a newborn immediately after birth? 1 To reduce the risk of jaundice 2 To reduce the risk of bleeding 3 To reduce the risk of cold stress 4 To reduce the risk of pneumonia

2 To reduce the risk of bleeding

While caring for a newborn, the nurse finds asymmetric gluteal folds in the newborn. Which complication does the nurse expect to find in the newborn? 1 Syndactyly 2 Down syndrome 3 Congenital hip dysplasia 4 Sudden infant death syndrome

3 Congenital hip dysplasia

The father's behavior when introduced to his new baby is typically an intense fascination. Which term describes this behavior? 1 Bonding 2 Taking-in 3 Engrossment 4 Enforcement

3 Engrossment

The nurse is caring for a postpartum patient who is administered oxytocin (Pitocin). Which symptoms should the nurse monitor for in the patient to ensure safe administration of the medication? Select all that apply. 1 Pyrosis 2 Swelling 3 Water intoxication 4 Irregular heartbeat 5 Decreased blood pressure

3 Water intoxication 4 Irregular heartbeat 5 Decreased blood pressure

Which medication does the nurse expect the health care provider to prescribe for the newborn with a white patchy coating on the oral mucous membrane that cannot be wiped off? 1 Ibuprofen (Advil) 2 Oxytocin (Pitocin) 3 Simethicone (Mylicon) 4 Nystatin (Mycostatin)

4 Nystatin (Mycostatin)

A Vietnamese mother changes her newborn's diaper and provides basic care but fails to cuddle, kiss, or talk to the infant. Which inference would the nurse make? 1 There is lack of bonding. 2 The mother is adapting to the new role. 3 The mother is exhausted from the delivery. 4 This behavior is normal for a mother of this culture.

4 This behavior is normal for a mother of this culture.

Why would the nurse place an ice pack on the perineum of the patient 4 hours after delivery? 1 To retain moisture 2 To prevent infection 3 To decrease swelling 4 To provide pain relief

4 To provide pain relief

Why would the postpartum patient with significant bleeding be prescribed an intravenous (IV) infusion of lactated Ringer's solution? 1 Pale yellow skin 2 Decreased pulse rate 3 Increased blood pressure 4 Weakness and frequent vomiting

4 Weakness and frequent vomiting

Which actions by the mother indicate the teaching of nipple care after breast-feeding was not effective? 1 Rubbing lanolin cream on both nipples after feeding 2 Using warm water to wash the nipples after each feeding 3 Allowing nipples to air-dry without removing the milk residue 4 Wiping each nipple thoroughly with an alcohol pad after feeding

4 Wiping each nipple thoroughly with an alcohol pad after feeding

The nurse is caring for a newborn who weighs 3 kg. What does the nurse expect should be the minimum daily intake of fluids in this newborn? Record your answer using a whole number. _____ mL/day

420

Which nursing intervention would be most suitable for a postpartum patient with an anterior rectal laceration? Select all that apply. 1 Instructing the patient to drink a lot of fluids 2 Administering stool softeners to the patient 3 Assessing the fecal continence of the patient 4 Suggesting the patient to avoid walking for a week 5 Administrating enemas or suppositories to the patient

1 Instructing the patient to drink a lot of fluids 2 Administering stool softeners to the patient 3 Assessing the fecal continence of the patient

A nurse is providing postpartum teaching to a patient about self-care after discharge. Which statement by the patient would require the nurse to reinforce teaching? 1 "I can't wait to soak in my Jacuzzi tub." 2 "I will follow up with my doctor in 6 weeks." 3 "I must wipe from front to back when I urinate." 4 "I should notify the health care provider if I have a fever."

1 "I can't wait to soak in my Jacuzzi tub."

Which data on the nursing documentation would indicate a potential complication in a patient 8 hours after cesarean delivery? 1 Apical pulse is 25 beats/min above predelivery baseline. 2 The patient's temperature remains at or below 100°F. 3 Blood pressure is within 10 mm Hg of patient's normal value. 4 Respirations are even and unlabored at 20 breaths/min.

1 Apical pulse is 25 beats/min above predelivery baseline.

Which action should the nurse take when a newborn has slightly blue hands and feet? 1 Continue to monitor the infant. 2 Administer oxygen, as prescribed. 3 Increase the heat on the warmer. 4 Wrap the infant in a warm blanket.

1 Continue to monitor the infant.

Which actions by the nursing mother will support milk production and promote infant comfort? Select all that apply. 1 Drinking 8 to 10 glasses of fluids daily 2 Avoiding spicy foods, chocolate, and onions 3 Drinking two or three alcoholic beverages per day 4 Continuing taking prenatal vitamins and minerals until they are gone 5 Consuming more protein and approximately 1500 extra calories daily

1 Drinking 8 to 10 glasses of fluids daily 2 Avoiding spicy foods, chocolate, and onions 4 Continuing taking prenatal vitamins and minerals until they are gone

A postpartum mother is being provided instructions about breast-feeding. Which statement by the patient indicates the nurse's instructions were misunderstood? 1 "I will wear a well-fitting and supportive bra." 2 "As long as I breast-feed, I can't get pregnant." 3 "Taking Tylenol before breast-feeding can help the pain." 4 "My breast can become engorged if I do not feed regularly."

2 "As long as I breast-feed, I can't get pregnant."

The nurse assesses the new mother's uterus and notes it to be boggy. Which intervention should the nurse perform first? 1 Instruct the patient to void. 2 Gently massage the fundus to increase contractility. 3 Contact the health care provider for an oxytocic medication. 4 Direct the patient to assume a lateral position with her upper leg drawn toward the chest.

2 Gently massage the fundus to increase contractility.

The nurse is caring for a patient who had a cesarean delivery and was administered general anesthesia. The nurse suggests that the patient walk at frequent intervals and avoid continuous bedrest. What could be the probable reason for this suggestion? 1 To help reduce the pain 2 To help promote bowel function 3 To help enhance milk production 4 To help avoid supine hypotension

2 To help promote bowel function

For which reason would the nurse advise a postpartum patient to place the newborn on the right side after feeding? 1 To facilitate voiding 2 To prevent regurgitation 3 To prevent suffocation 4 To enhance blood supply

2 To prevent regurgitation

The nurse advises a postpartum patient to fold her baby's diaper down such that the plastic side is facing outside for proper umbilical cord care. Which occurrence would following this advice prevent? 1 Severance of the umbilicus 2 Redness near the umbilicus 3 Foul odor from the umbilicus 4 Moisture retention in the umbilicus

4 Moisture retention in the umbilicus

Which medications would the nurse anticipate administering to all newborns admitted to the nursery? Select all that apply. 1 Oxytocin (Pitocin) 2 Witch hazel (Tucks) 3 Erythromycin drops 4 Vitamin K (AquaMEPHYTON) 5 Benzocaine (Dermoplast spray)

3 Erythromycin drops 4 Vitamin K (AquaMEPHYTON)

Which nursing intervention would best allow for the nurse to assess a postpartum patient for Homans' sign? 1 Have the patient lie on the left side and extend the legs. 2 Have the patient lie supine, cross the legs, and point the toes. 3 Have the patient lie flat and point the toes toward the ankles. 4 Raise the head of the bed, and have the patient point the toes toward the ceiling.

3 Have the patient lie flat and point the toes toward the ankles.

A new mother reports feeling weak, lightheaded, and sick to her stomach. The licensed practical/vocational nurse (LPN/LVN) also notes that the patient's perineal pad is soaked since she last checked it 15 minutes ago. The patient's skin is cool and clammy, and her pulse is 110 beats/min and blood pressure is 80/60 mm Hg. Which complication do these symptoms indicate? 1 Preeclampsia 2 Puerperal infection 3 Hypovolemic shock 4 Pregnancy-induced hypertension

3 Hypovolemic shock

The nurse is reviewing the lab reports of a postpartum patient and the newborn and expects the health care provider to prescribe RhoGAM to the patient. Which finding enabled the nurse to reach this conclusion? 1 The patient and the newborn are both Rh positive. 2 The patient and the newborn are both Rh negative. 3 The patient is Rh negative, and the newborn is Rh positive. 4 The patient is Rh positive, and the newborn is Rh negative.

3 The patient is Rh negative, and the newborn is Rh positive.

The student nurse observes that the patient holds the breast away from the infant's nostrils while feeding the infant. Which understanding would the student nurse have regarding this action? 1 The patient is trying to protect the newborn's oral mucosa. 2 The patient is encouraging the newborn to latch on and feed. 3 The patient is trying to promote proper respiration in the infant. 4 The patient is having severe pain while holding the breast for breast-feeding.

3 The patient is trying to promote proper respiration in the infant.

Which statement regarding jaundice is accurate? 1 The discoloration occurs in all infants and is a normal process. 2 The yellow color will most likely disappear within 7 to 10 days. 3 This jaundice is likely related to maternal-fetal blood incompatibility. 4 This is a permanent condition and the infant's skin will retain this color.

3 This jaundice is likely related to maternal-fetal blood incompatibility.

While caring for a postpartum patient with severe lacerations and hemorrhage, the nurse is preparing to provide a disposable type of sitz bath. In which order should the nurse perform the procedure? 1. Place the container above the toilet bowl. 2. Raise the toilet seat, and place the bath in the bowl. 3. Clamp the tubing, and fill the bag with warm water. 4. Loosen the tube clamp to regulate the rate of flow. 5. Attach the tube into the groove at the front of the bath.

3. Clamp the tubing, and fill the bag with warm water. 2. Raise the toilet seat, and place the bath in the bowl. 1. Place the container above the toilet bowl. 5. Attach the tube into the groove at the front of the bath. 4. Loosen the tube clamp to regulate the rate of flow.

A patient who had a cesarean section is due to be discharged home. Which data obtained during an assessment would be of concern to the nurse? 1 Scant bloody nonodorous discharge is noted. 2 Patient is awake, alert, and oriented to person, place, and time. 3 Abdomen is soft and slightly protruding, with active bowel sounds in four quadrants. 4 Abdominal incision is red and warm, and edges are nonapproximated, with moderate exudate.

4 Abdominal incision is red and warm, and edges are nonapproximated, with moderate exudate.

Which intervention does the nurse expect to be most beneficial for an infant with severe bleeding after circumcision? 1 Applying 2% phenol at the site of bleeding 2 Cleaning continuously at the site of bleeding 3 Applying gentle pressure at the site of bleeding 4 Arranging for the ligation of the bleeding blood vessel

4 Arranging for the ligation of the bleeding blood vessel

A nurse observes a new mother turning away from her infant and sighing deeply. Which intervention would be most appropriate for the nurse? 1 Ignore this because it is common after childbirth. 2 Assess the new mother for pain and offer analgesics, as prescribed. 3 Inform the chaplain that the patient may require spiritual counseling because she is rejecting her infant. 4 Encourage the new mother to discuss her feelings by sitting next to her and stating, "Having a baby can be overwhelming."

4 Encourage the new mother to discuss her feelings by sitting next to her and stating, "Having a baby can be overwhelming."

The vital signs of a newborn baby girl are as follows: T 97.9°F, P 140, R 34 with brief periods of apnea, and BP 80/40 with an increase in systolic pressure when crying. Which nursing action would be best? 1 Assess lung sounds because of a high respiratory rate with apnea. 2 Check the baby's blood glucose level because her temperature is low for a newborn. 3 Notify the health care provider because the baby's heart rate reveals tachycardia. 4 Realize these vital signs are normal for a newborn, and document the data on the flow sheet.

4 Realize these vital signs are normal for a newborn, and document the data on the flow sheet.

The infant is passing very watery and green stools after the transition stools. Which inference does the nurse conclude from these findings? 1 The infant lacks intestinal flora. 2 The infant is given formula milk. 3 The mother drinks excessive fluids. 4 The infant has gastrointestinal irritation.

4 The infant has gastrointestinal irritation.

An infant requires 160 mL of intravenous (IV) rehydration fluids per kilogram daily. How many milliliters will an infant weighing 8 pounds require in a 24-hour period? Record your answer to the nearest whole number. _____ mL

581 mL