Exam 5 Women and Children Chapters: 12, 13, 14, 15, 19, 20, 21 PrepU

A nurse is observing the interaction between a new father and his newborn. The nurse determines that engrossment has yet to occur based on which behavior?

identifies imperfections in the newborn's appearance; Identifying imperfections would not be associated with engrossment. Engrossment is characterized by seven behaviors: visual awareness of the newborn, tactile awareness of the newborn, perception of the newborn as perfect, strong attraction to the newborn, awareness of distinct features of the newborn, extreme elation, and increased sense of self-esteem.

A nurse is teaching a postpartum client how to do muscle-clenching exercises for the perineum. The client asks the nurse, "Why do I need to do these exercises?" Which reason would the nurse most likely incorporate into the response?

improves pelvic floor tone

The postpartum client is reporting her left calf hurts and it is making it difficult for her to walk. The nurse predicts which factor is contributing to this situation after finding an area of warmth and redness?

increased coagulation factors

The nurse is assessing a postpartum woman and is concerned the client may be hemorrhaging. Which assessment finding is the nurse finding most concerning?

increased heart rate

21 The parent reports that the health care provider said that the infant had a hernia but cannot remember which type. When recalling what the health care provider said, the parent said that a surgeon will repair it soon and there is no problem with the testes. Which hernia type is anticipated?

inguinal hernia

19 A nurse is developing a program to help reduce the risk of late postpartum hemorrhage in clients in the labor and birth unit. Which measure would the nurse emphasize as part of this program?

inspecting the placenta after delivery for intactness

20 What is the most common reason why an infant will be small-for-gestational-age (SGA)?

intrauterine growth restriciton

20 A preterm newborn is noted to have hypotonia, apnea, bradycardia, a bulging fontanel (fontanelle), cyanosis, and increased head circumference. These signs indicate the newborn has which complication?

intraventricular hemorrhage (IVH)

19 An Rh-positive client gives birth vaginally to a 6 lb, 10 oz (3,005 g) neonate after 17 hours of labor. Which condition puts this client at risk for infection?

length of labor

When caring for a mother who has had a cesarean birth, the nurse would expect the client's lochia to be:

less than after a vaginal birth.

The nurse assesses a postpartum client's discharge as being moderate in amount and red in color. How should the nurse document the appearance of the lochia?

lochia rubra

The nurse is concerned that a new parent is developing a postpartum complication. What did the nurse most likely assess in this client?

lochia that has an offensive odor

14 A newborn's parents ask the nurse how to prevent the newborn from becoming ill. What is the best response by the nurse?

"Always wash your hands before you pick up or provide care to your newborn."

A client who recently gave birth to her third child expresses a desire to have her older two children come to the hospital for a visit. What should the nurse say in response to this request?

"As long as they are well, absolutely. Why don't we give you a dose of pain medication beforehand so that you will enjoy the visit?"

20 The nursing students describe the infant they are caring for as weighing 2000 g. The instructor knows that effective communication among staff members suggests that what term be used to describe the infant?

low-birth-weight (LBW)

19 The nurse is administering a postpartum woman an antibiotic for mastitis. Which statement by the mother indicates that she understood the nurse's explanation of care?

"I can continue breastfeeding my infant, but it may be somewhat uncomfortable."

21 The nurse is caring for an infant with a myelomeningocele prior to surgical repair. Which nursing consideration is the highest priority?

maintaining a clean environment

19 A postpartum client saturates a peripad in 30 minutes. What is the nurse's first action in this situation?

massage the fundus

19 When monitoring a postpartum client 2 hours after birth, the nurse notices heavy bleeding with large clots. Which response is most appropriate initially?

massage the fundus firmly

19 The nurse is assessing the breast of a woman who is 1 month postpartum. The woman reports a painful area on one breast with a red area. The nurse notes a local area on one breast to be red and warm to touch. What should the nurse consider as the potential diagnosis?

mastitis

20 A newborn has been diagnosed recently with transient tachypnea of the newborn. How should the nurse counsel the parents?

"I know it's scary now, but this condition most likely will resolve on its own without affecting your baby in the long run."

A mother's chart notes that she is non-immune on her rubella status. The nurse explains what this means to the client. Which statement by the mother indicates that more teaching is needed?

"I need to have three shots to get my rubella levels up."

The nurse provides discharge instructions to a postpartum client. Which client statement indicates that teaching has been effective?

"I should plan to return to my full-time job after 6 weeks."

A nurse is conducting discharge teaching with a first-time mother. The nurse is teaching the client about lochia flow and how to evaluate it. The nurse determines that the teaching was successful based on which client statement?

"If I saturate a perineal pad in under an hour, I need to call my provider."

A newly delivered mother asks the nurse "What can I do to help my womb to get back to a normal size more quickly?" The nurse's best response would be:

"If you are breastfeeding, that will help make your uterus contract and get smaller."

20 The parents of an 8-month-old tell the nurse that they have a fear that the infant will develop sudden infant death syndrome (SIDS). What is the best response by the nurse?

"Infants who die from SIDS are usually 2 to 4 months old, but I understand your concern."

14. A nurse is teaching new parents about caring for their newborn's umbilical cord. The nurse determines that the teaching was successful based on which statement made by the parents?

"It is important that we keep the area dry."

A new mother is concerned because it is 24 hours after birth and her breasts have still not become engorged with breast milk. How should the nurse respond to this concern?

"It takes about 3 days after birth for milk to begin forming."

19 A postpartum client is prescribed medication therapy as part of the treatment plan for postpartum hemorrhage. Which medication would the nurse expect to administer in this situation?

methylergonovine

The nurse is preparing a new mother to be discharged home after an uncomplicated delivery. During discharge education, which type of lochia pattern should the nurse tell the woman is abnormal and needs to be reported to her health care provider immediately?

moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5

A 2-day old newborn is crying after being circumcised and the mother is attempting to comfort the infant but he continues to be fussy. Which statement by the nurse would best support the mother's actions?

"Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure."

An 20-year-old primipara is getting ready to go home. She had a second-degree episiotomy with repair. She confides in the nurse that she is afraid to go to her postpartum checkup because she is afraid to have the stitches removed. Which reply by the nurse is best?

"Many women have that fear after having an episiotomy. The stitches do not need to be removed because the suture will be gradually absorbed."

A woman who delivered her infant 2 days ago asks the nurse why she wakes up at night drenched in sweat. She is concerned that this is a problem. The nurse's best reply would be:

"Sweating is very normal for the first few days after childbirth because your body needs to get rid of all the excess water from pregnancy."

A client who is breastfeeding her newborn tells the nurse, "I notice that when I feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now?" Which response by the nurse would be most appropriate?

"The baby's sucking releases a hormone that causes the uterus to contract."

19 The nurse is caring for several women in the postpartum clinic setting. Which statement(s), when made by one of the clients, would alert the nurse to further assess that client for postpartum psychosis? Select all that apply.

"The newborn is not really mine emotionally, since I was never pregnant and do not have children." "When the newborn is sleeping, I can see his thoughts projected on my phone and I do not like the thoughts." "I believe my newborn is losing weight because I will not feed him because my milk was poisoned by the health care provider."

20 A nurse notices a mother in the NICU crying next to her premature 25-week-old neonate. What is the most appropriate response by the nurse?

"This situation must be difficult for you. Can you tell me what concerns you have right now?"

21 The nurse is caring for a newborn client newly diagnosed with developmental dysplasia of the hip (DDH). Which response by the nurse educates the parents on the correct plan of treatment for this diagnosis?

"Treatment will begin immediately."

21 A newborn boy is diagnosed with esophageal atresia and tracheoesophageal fistula. After the nurse provides preoperative teaching, which statement indicates that the parents need additional teaching?

"We can probably start feeding him with the bottle about a day after the surgery."

14 A nurse is teaching a newborn's caregivers how to change a diaper correctly. Which statement by the caregiver best indicates the nurse's teaching was effective?

"We will fold down the front of her diaper under the umbilical cord until it falls off."

19 The nurse is providing education to a postpartum woman who has developed a uterine infection. Which statement by the woman indicates that further instruction is needed?

"When I am sleeping or lying in bed, I should lie flat on my back."

14 A parent asks the nurse how to swaddle the newborn because the parent heard that it helps newborns calm down. Which statement will the nurse include in the teaching?

"Wrapping the newborn too tightly can impair breathing."

14 The nurse is teaching the parents of a newborn baby girl the basic discharge instructions. The nurse determines the session is successful after the couple articulate they will contact the primary care provider if their infant shows which sign of diarrhea?

more than two episodes of diarrhea in one day

20 The nurse in the newborn nursery has used the Ballard scoring system to assess the newborn. This gestational assessment evaluation includes which of the following categories of maturity of the newborn?

neuromuscular and physical

20 A newborn is found to have hemolytic disease. Which combination would be found related to the blood types of this newborn and the parents of the newborn?

newborn who is type A, mother who is type O

19 The nurse is assigned to care for a postpartum client with a deep vein thrombosis (DVT) who is prescribed anticoagulation therapy. Which statement will the nurse include when providing education to this client?

"You need to avoid medications which contain acetylsalicylic acid

20 A 6-week-old infant has stopped breathing and the parent stimulates the infant. The infant's respirations resume. The infant is transported to the hospital. What nursing intervention(s) will the nurse include in the immediate plan of care? Select all that apply.

*Connect the infant to continuous monitoring *Obtain a complete history of the event *Perform a comprehensive assessment

13 Which physical findings would the nurse observe in a newborn that would indicate that the newborn is full-term? SATA

*Fingernails are present and extend to the end of the fingers *Pinnae are flexible with rapid recoil *Creases on the feet cover 2/3 of the bottom of the feet

14 The nurse is preparing to administer an intramuscular injection of vitamin K to a newborn. The nurse will ensure the amount per injection is within which range?

0.5 to 1.0 mg

14 A newborn weighing 5 lb (2250 g) needs to eat 3 oz (90 ml) of formula every 3 hours. To meet this goal, how many ounces of formula per day will the parent need to feed the newborn? Record your answer using a whole number.

24

14 Neonatal screening is done before the infant leaves the hospital. Blood is drawn through a heel stick and tested for several disorders that can cause lifelong disabilities. When is the ideal time to collect this specimen?

24 hours after the newborn's first protein feeding

19 The nurse is caring for a client who has given birth to twins. During which time period would the nurse instruct on the possibility of a late postpartum hemorrhage?

24 hours to 12 weeks after birth

20 he nurse is completing accurate output on a preterm client. The nurse changed the client's diaper, which weighs 50 g. The dry diaper weighs 22 g. Which amount does the nurse record under output? Record your answer using a whole number.

28 g

13 The nurse has completed assessing the blood glucose levels of several infants who are 24 hours old. Which result should the nurse prioritize for intervention?

30 mg/dL

20 A newborn who is large for gestational age will weigh more than ______ grams.

4000

20 The nurse is caring for a client who is at her due date. The client asks. "How long is the health care provider going to let me go?" The nurse is correct to state that typical a mother should not pass how many weeks' gestation?

42 weeks

13 A hypoglycemic newborn will have a blood glucose reading of what value on a heel stick?

45 mg/dl Anything below 50 mg/dl in a newborn is considered to be hypoglycemia

19 The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount?

500mL

21 When planning preoperative care for a newborn with a cleft lip and palate, the nurse would plan interventions for which major need?

nutrition

14 During a childbirth class, the nurse talks to the parents about how to prevent infant abductions in the hospital by recognizing the profile of an abductor. Which person best fits the profile of a typical infant abductor?

A female in her mid-20s who appears pregnant

19 A woman recovering from cesarean birth in the hospital and who was catheterized complains of a feeling of burning on urination and a feeling of frequency. Which of the following should be the next nursing action?

obtain a clean-catch urine specimen

21 A new mother is concerned because she fears that her infant's head is larger than normal. What would be the nurse's best response?

A large head at birth in itself is not indicative of hydrocephalus, but we will keep a check on it.

21 A newborn was diagnosed as having hypothyroidism at birth. The parent asks the nurse how the disease could be discovered this early. Which is the nurse's best answer?

A simple blood test to diagnose hypothyroidism is required in most states.

19 A nurse is caring for a client in the clinic. The client reports burning during urination for the past few days. Assessment reveals cloudy urine, with the presence of white blood cells (WBCs). Vital signs: temperature, 101.4°F (38.5°C); heart rate, 101 beats/min; blood pressure, 100/64 mm Hg. Complete the following sentence(s) by choosing from the lists of options. The priority actions of the nurse should be to first

obtain a culture and initiate antibiotics

21 It would be best to place an infant with a meningomyelocele in which position prior to surgery?

on the stomach (prone)

20 The nurse is caring for a neonate that is small for gestational age due to intrauterine growth restriction. Which is the most common cause?

oxygen and nutrient deficiency prior to birth

A nurse is caring for a client who is nursing her baby boy. The client reports afterpains. Secretion of which substance would the nurse identify as the cause of afterpains?

oxytocin

20 The nurse is providing care to a newborn with severe meconium aspiration syndrome (MAS). The nurse is reviewing the newborn's diagnostic test results. Which finding would the nurse expect?

patchy, fluffy infiltrates on chest x-ray

21 A 5-month-old is having a cleft lip/palate repair. What games could the nurse play with the child to provide comfort and diversion postoperatively while the baby is in elbow restraints?

peek-a-boo

13 Which factor would demonstrate physiologic respiratory adaptation to extrauterine life in a newborn infant?

Abrupt temperature change upon delivery, causing a cry

After the birth of the newborn, the mother is ready to be discharged home. The client's mother is present and will remain with her for 1 month. The client's mother tells the nurse that her daughter will not be allowed to leave the house for the first month after the birth, based on the family's cultural customs. How should the nurse respond to this statement?

Accept the mother's statement and perform discharge teaching accordingly.

21 Which clinical manifestation is seen in the child with hydrocephalus?

An extremely large and rapidly growing head

21 Immediately after birth, the nurse is caring for a newborn with a myelomeningocele. What intervention should the nurse provide to prevent drying out of the sac to avoid damage?

Apply a sterile dressing moistened in a warm, sterile saline solution.

19 When completing the morning postpartum data collection, the nurse notices the client's perineal pad is completely saturated. Which action should be the nurse's first response?

Ask the client when she last changed her perineal pad

The nurse is used to working on the postpartum floor taking care of women who have had normal vaginal births. Today, however, the nurse has been assigned to help care for women who are less than 24 hours post-cesarean birth. The nurse realizes that some areas will not be assessed. What would the nurse leave out of the client assessments?

perineum

14 A woman in scrubs enters a mother's room while the nurse is completing an assessment. The woman states the doctor is in the nursery and has requested the infant be brought back for an examination. What will the nurse do?

Ask to see the woman's hospital ID badge

21 A nurse is caring for a newborn client diagnosed with spina bifida. Which assessment finding would be a priority for the nurse who is monitoring for the risk of hydrocephalus?

Assess head circumference measurements.

314 The parents of a newborn become concerned when they notice that their baby seems to stop breathing for a few seconds. After confirming the parents' findings which action should the nurse prioritize?

Assess the newborn for signs of respiratory distress

20 What is the responsibility of the registered nurse (RN) after the delivery of the newborn? Select all that apply.

Assessing the gestational age Identifying potential Complications Initiating the Plan of Care

19 Which assessment would lead the nurse to believe a postpartum woman is developing a urinary complication?

At 8 hours postdelivery she has voided a total of 100 mL in four small voidings

20 The licensed practical nurse (LPN) is caring for a neonate who is 24 hours old and notes the apnea and bradycardia monitor alarming. Upon entering the room, the nurse reads a respiratory rate of 84 breaths/minute and a heart rate of 200 beats/minute on the client's monitor. Which action will the LPN take next?

Auscultate the neonate's lungs and heart.

19 The nurse is giving an educational presentation to the local Le Leche league chapter. One woman asks about risk factors for mastitis. Which condition would the nurse most likely include in the response?

pierced nipple

A nurse notes a woman's prelabor vital signs were: temperature 98.8° F (37.1° C); blood pressure 120/70 mm Hg; heart rate 80 beats/min; and respirations 20 breaths/min. Which assessment findings during the early postpartum period should the nurse prioritize?

BP 90/50 mm Hg, heart rate 120 bpm, respirations 24 breaths/min.

21 Which health care provider assessment technique does the nurse anticipate being used to determine developmental dysplasia of the hip (DDH) on a newborn?

Barlow sign and Ortolani click

13 A nurse is caring for an infant with an elevated bilirubin level who is under phototherapy. What evaluation data would best indicate that the newborn's jaundice is improving?

Bilirubin level went from 15 to 11

13 A newborn's vital signs are documented by the nurse and are as follows: HR 144, RR 36, BP 128/78, T 98.6F. Which finding would be concerning to the nurse?

Blood pressure

14 The nurse is performing an assessment on a neonate. Which assessment finding should the nurse prioritize as suggestive of hypothermia?

Bradycardia

14. The nurse notices that there is no vitamin K administration recorded on a newborn's medical record upon arrival to the newborn nursery. What would be the nurse's first action?

Call the L&D nurse who cared for the newborn to inquire about why the medication was not documented

20 A nurse makes a home visit to a new mother and her 5-day-old newborn. Assessment of the newborn reveals slight yellowing of the skin on the face and forehead and slowed skin turgor. The mother tells the nurse that she's been having trouble breastfeeding the newborn. "My baby's been feeding about every 4 to 5 hours." Additional assessment reveals about 3 wet diapers per day and 1 to 2 stools per day. Which action by the nurse would be the priority?

Call the provider to obtain a prescription for a bilirubin level

13 A nurse is called into the room of one of the clients where the grandparents are visiting. The grandmother is visibly upset, and says "Just look at my grandson! His head is all soft and swollen here and it shouldn't be. The doctor injured him when he was born." The nurse assesses the newborn and finds an area of swelling about the size of a half-dollar at the center of the upper scalp. The nurse determines this finding is most likely which condition?

Caput succedaneum

14 The nurse explains the hospital's home visitation program for new families after discharge from the hospital. Which information will the nurse include regarding this program?

Caregivers can demonstrate competency in caring for the infant and ask questions

20 The nurse is providing the initial assessment and care to a newborn. Which potential infection will the nurse help prevent by administirng ophthalmic erythromycin to this newborn?

Chlamydia trachomatis

19 It is discovered that a new mother has developed a postpartum infection. What is the most likely expected outcome that the nurse will identify for this client related to this condition?

Client's temperature remains below 100.4°F (38.8°C) orally.

21 A dietitian is consulted to assist with the planning of meals for a family that must follow a low phenylalanine diet since their child is now 2 years old and eating more table foods. Which instruction is anticipated? Select all that apply.

Common foods must be eliminated. The child must remain on the diet until early adulthood. Meats and fish must be eliminated. Care must be provided when eating out

14 What is priority for the nurse to do when transporting a newborn back to the mother after completing the hearing test?

Compare the ID bracelets prior to leaving the newborn with the mother

20 All of the following complications are more likely to develop in a large-for-gestational-age (LGA) newborn as opposed to an appropriate-for-gestational-age (AGA) newborn except: a. cesarean delivery b. breech presentation c. shoulder dystocia d. polycythemia

polycythemia

A nurse is providing education to a client experiencing postpartum blues. The nurse determines client understanding when the client makes which of statements regarding factors that contribute to postpartum blues, signs and symptoms associated with postpartum blues, and collaborative care to treat symptoms?

Contributing Factors: -"Postpartum blues are due to changes in hormones." -"Postpartum blues are due to fatigue." S/S: - "A symptom of postpartum blues is being emotionally labile up to 10 days postpartum." Collaborative Care: -"Sleep hygiene can help with postpartum blues." -"Adequate nutrition can help with postpartum blues." -"Regular physical exercise can help with postpartum blues." -"Ensuring adequate support for newborn care can help with postpartum blues."

19 A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented, and the client frequently indulges in obsessive concerns. The nurse notes that the client has difficulty relaxing and sleeping. The nurse interprets these findings as suggesting which condition?

post-partum psychosis

20 A newborn is admitted to the nursery after being born at 43 weeks' gestation. This newborn is classified as which of the following?

post-term

The nurse is assessing a client at a postpartum visit and notes the client is emotionally sensitive, complains about being a failure, and appears extremely sad. The nurse concludes the client is presenting with which potential condition?

postpartum depression

14 A nursing instructor is conducting a class on the topic of circumcision. The instructor determines the class needs more education when they choose which factor as an advantage for having a circumcision?

Decreases risks of skin dehiscence, adhesions, and urethral fistulas

21 The parent has brought a 2-year-old to the public clinic for immunizations. The nurse documents the following characteristics: A duck waddle gait Shortened extremity Asymmetry of the gluteal folds Protruding abdomen The nurse then refers the toddler to the health care provider for potential diagnosis of which?

Developmental dysplasia of the hip (DDH)

14 Which action would be priority for the nurse to complete immediately after the delivery of a 40-week gestation newborn?

Dry the newborn and place it skin-to-skin on mother

19 A woman who gave birth to an infant 3 days ago has developed a uterine infection. She will be on antibiotics for 2 weeks. What is the priority education for this client?

Encourage an oral intake of 2 to 3 liters per day.

A multigravida client is still focusing on her difficult labor and discusses it with the nurse at each opportunity, several hours after the birth. Which action should the nurse prioritize after noting the client's partner is spending more time with the infant than the client?

Encourage her to discuss her experience of the birth and answer any questions or concerns she may have.

14 A nurse is observing a new parent bottle feeding the newborn. The nurse notices that the newborn begins to get fussy during the feeding. Which action by the nurse would be appropriate?

Encourage the parent to burp the newborn to get rid of air

A nurse is developing a plan of care for a postpartum woman, newborn, and partner to facilitate the attachment process. Which intervention would be appropriate for the nurse to include in the plan?

Ensure early and frequent parent-newborn interactions.

A G4P4 mother calls the nurse's station reporting uterine pain following birth. When the nurse responds to the call, the mother reports that she is having what feels like labor pains again off and on. What would be the nurse's response?

Explain to her that women who have had several babies prior to this delivery often experience afterpains, which is where the uterus is contracting and relaxing at intervals.

14 A new mother calls her pediatrician's office concerned about her 2-week-old infant "crying all the time." When the nurse explores further, the mother reports that the infant cries at least 2 hours each day, usually in the afternoons. What recommendation would the nurse not make to this mother?

Feeding the infant more formula whenever she begins to fuss Swaddling, a soothing touch, and gentle pats on the back all help calm a fussy infant.

19 A client is diagnosed with a postpartum infection. The nurse is most correct to provide which instruction?

Finish all antibiotics to decrease a genital tract infection.

20 A nurse in the hospital nursery cares for a preterm newborn, born at 30 weeks' gestation. The newborn had an APGAR score of 6 at 1 minute (1 point for color, 1 point for respiratory effort, 1 point for muscle tone, 1 point for reflex, 2 points for heart rate) and 8 at 5 minutes. The newborn has a lot of vernix on the whole body, acrocyanosis of the hands, a glucose level of 40 mg/dl (2.22 mmol/l), and a temperature of 96.1°F (35.6°C). Drag words from the choices below to fill in each blank in the following sentence. To prevent problems for the newborn, the action that the nurse must implement first is ______________ followed by ______________________ next. a. dry newborn to prevent hypothermia observe for hypothermia observe for respiratory distress observe for hyperglycemia monitor the newborn's glucose level monitor for acrocyanosis

First: dry newborn to prevent hypothermia Followed by: observe for respiratory distress

13 The nurse reads the laboratory report on a newborn (above). What action will the nurse take? WBC: 6,000 cells/mm3 Potassium: 4.2 mEq/dl Glucose: 38 mg/dl

Further assess the newborn for hypoglycemia

21 From which pair of metabolic disorders must the nurse instruct the parents to eliminate breast and cow's milk from the diet?

Galactosemia and phenylketonuria

14. The nurse is caring for a newborn whose mother tested positive for hepatitis B surface antigen (HBsAg). Which intervention(s) will the nurse perform? Select all that apply.

Give hepatitis B immune globulin Obtain consent from the mother Admin Hepatitis B vaccination Bathe the newborn thoroughly

14 A nurse in the hospital is caring for a client at 37 weeks' gestation who experienced premature rupture of the membranes (PROM) more than 24 hours prior to coming to the hospital. The client presents with a fever of 100.4°F (38°C). Complete the following sentence(s) by choosing from the lists of options. Due to the client's PROM more than 24 hours prior to arriving to the hospital, the nurse determines the client is at risk for contracting: _________________________________ and should plan to implement _______________________________

Group B Strep Administer IV Antibiotics

A nurse is performing an assessment on a female client who gave birth 24 hours ago. On assessment, the nurse finds that the fundus is 2 cm above the umbilicus and boggy. Which intervention is a priority?

Have the client void, and then massage the fundus until it is firm.

13 A nurse is conducting a refresher in-service program for a group of neonatal nurses. The nurse determines the session is successful after the participating nurses correctly choose which factor is responsible for the appearance of jaundice in the newborn?

Hemolysis of erythrocytes

14 The nurse is caring for a newborn with a mother who has a positive hepatitis B surface antigen (HBsAg) test. Which of the following can the nurse expect the newborn to receive? Select all that apply.

Hepatitis B Vaccination Hepatitis B immune globulin

19 Which assessment on the third postpartum day would indicate to the nurse that a woman is experiencing uterine subinvolution?

Her uterus is at the level of the umbilicus.

21 The nurse is caring for a neonate in the newborn nursery with clubfoot (congenital talipes equinovarus). If nonsurgical treatment is chosen, which nursing action is anticipated?

Holding feet/ankles in position for casting

20 The nurse is caring for a post-term neonate. Which assessment findings are congruent with the age determination? Select all that apply.

Hyperalert Expression Dry, cracked and peeling skin Little Vernix Remains Little Subcutaneous Fat Long Fingernails

14 A nurse is preparing to administer phytonadione to a newborn. After confirming the order, what will the nurse do next?

Identify the newborn.

21 In completing the newborn assessment checklist, the nurse documents a meconium stool. This documentation rules out which condition?

Imperforate anus

14 A newborn's cord begins to bleed 1 day following birth. What measures would the nurse take to address this problem?

Inspect the clamp to insure that it is tightly closed and applied correctly.

14 The head nurse of the newborn nursery is teaching new employees ways to reduce the transmission of infection in the nursery. What information would be included in this session?

Keep all of the newborn's belongings together in the bassinet.

What two elements play the biggest role in becoming a mother after delivery of her newborn?

Love and attachment to the child and engagement with the child

Chapter 12

Mary's Section

The nurse is admitting to the floor a woman who just gave birth. What medical and pregnancy history would the labor and delivery nurse include in the report?

Maternal blood type; Medical and pregnancy history would include information pertinent to the mother, which would be the mother's blood type, Rh, and rubella status. History of the length of labor are part of the labor and birthing history. The infant's Apgar scores and birth weight are part of the newborn history.

A new mother exhibits signs of feeling abandoned shortly before being released from the hospital. The mother gave birth to a healthy newborn 2 days ago. Which nursing intervention would be most appropriate in this case?

Mention to the mother how it is common to feel "left out" when all of the attention shifts from the pregnant mother to the newborn.; Many mothers, if given the opportunity, admit to feeling abandoned and less important after giving birth than they did during pregnancy or labor. Only hours before, after all, they were the center of attention, with everyone asking about their health and well-being. Now, suddenly, the baby is everyone's chief interest. You can help a woman move past these feelings by verbalizing the problem: "How things have changed! Everyone's asking about the baby today and not about you, aren't they?" These are reassuring words for a woman and help her realize, although uncomfortable, the feeling she is experiencing is normal. Commenting on a newborn's good points would be more appropriate if the mother is experiencing disappointment with the child. An explanation of how hormonal changes contribute to overwhelming sadness would be more appropriate in the case of postpartal blues. Referral to a psychologist would be more appropriate for a case of postpartal depression.

20 At birth, a newborn is diagnosed with brachial plexus palsy. The parent asks how the nurse knows the newborn's positioning of the arm is a result of the palsy and not just a preferred position. Which neonatal reflex should the nurse explain to the parent?

Moro Reflex

20 When providing care to the newborn withdrawing from a drug such as cocaine or heroin, which drug is given to ease the symptoms and prevent complications?

Morphine

14 The nurse completes the initial assessment of a newborn. Which finding would lead the nurse to suspect that the newborn is experiencing difficulty with oxygenation?

Nasal Flaring

14 Newborns receive an antibiotic in their eyes within the first hour after birth to prevent neonatorum ophthalmia. Which type of bacteria is most likely to cause this condition?

Neisseria gonorrhoeae

A woman who delivered her newborn by cesarean birth is admitted to the postpartum unit. During the delivery, the mother received two doses of morphine sulfate. The nurse notes that the client's respiratory rate is 11 and her oxygen saturation is 93%. What should the nurse do first?

Notify the health care provider of the findings.

21 A nurse is conducting an assessment of a 13-month-old infant. The parent notes that the infant cannot pull oneself into a standing position. To help determine a cause, which assessment will the nurse conduct?

Observe symmetry of gluteal skin folds.

21 The nurse is caring for a neonate with epispadias. In which location will the nurse assess the anomaly?

On the dorsal end of the penis

13 What is the first action taken by a nurse caring for a newborn with suspected hypoglycemia?

Perform a heel stick to obtain a blood sample for testing for glucose level

14 A nurse removes and discards a newborn's diaper before placing the newborn on the scales for a daily weight. The nurse realizes there are no clean diapers at the scale. The supply closet is located down the hallway. What will the nurse do?

Place newborn in the bassinet and cover with blanket while obtaining diapers.

20 A new mother is nervous about sudden infant death syndrome (SIDS) and asks the nurse how to prevent it when the newborn is ready to sleep. Which suggestions should the nurse include in the answer? Select all that apply.

Place the infant on his/her back Do not allow anyone to smoke around the infant

14. The parents of a 2-day-old newborn are preparing for discharge from the hospital. Which teaching is most important for the nurse to include regarding sleep?

Place the infant on the back when sleeping

14 The parents of a 2-day-old newborn are preparing for discharge from the hospital. Which teaching is most important for the nurse to include regarding sleep?

Place the infant on the back while sleeping

21 A nurse is caring for a newborn client who is diagnosed with myelomeningocele. Which nursing intervention would protect the newborn from injury?

Place the newborn in a prone or lateral position.

14. A laboring mother requests that she be allowed to participate in "kangaroo care" following the birth. The nurse understands that this involves what action?

Placing the diapered newborn skin-to-skin with the mother and covering them both with a blanket.

21 A nurse is caring for a newborn with a repaired cleft lip. What intervention can the nurse provide to facilitate drainage of mucus and secretions to prevent aspiration?

Position the child on the side.

14 The nurse administers vitamin K intramuscularly to the newborn based on which rationale?

Promote blood clotting

20 Which environmental consideration is most helpful to promoting comfort when the neonate is withdrawing from alcohol and drugs?

Provide a dark, quiet environment

14 Under which circumstances should gloves be worn in the newborn nursery? Select all that apply.

Providing the first bath changing a diaper performing a heel stick Accucheck

13 A nurse is explaining to a group of new parents about the changes that occur in the neonate to sustain extrauterine life, describing the cardiac and respiratory systems as undergoing the most changes. Which information would the nurse integrate into the explanation to support this description?

Pulmonary vascular resistance (PVR) is decreased as lungs begin to function

14 Just after birth, a newborn's axillary temperature is 94°F (34.4°C). What action would be most appropriate?

Rewarm the newborn gradually

20 The student nurse is performing a Ballard scale on a newborn. The instructor assesses that the student understands methods to check neuromuscular maturity when she gently pulls the newborn's arm in front of and across the top portion of the body until resistance is met and identifies this action as:

Scarf Sign

20 Which nursing action is required when caring for the post-term infant?

Serial Blood Glucose Levels

19 Which recommendation should be given to a client with mastitis who is concerned about breastfeeding her neonate?

She should continue to breastfeed; mastitis will not infect the neonate

20 Which nursing actions limit overstimulation of the preterm infant? Select all that apply.

Speak softly to the infant Keep lights low in the nursery Coordinate nursing care

21 The nurse is assessing the neonate shown. From the assessment, the nurse notes that there is paralysis of the lower extremities. For which condition does the nurse anticipate performing care?

Spina bifida with myelomeningocele

13 A nurse is assessing a newborn. Which finding would alert the nurse to the possibility of respiratory distress in a newborn?

Sternal retractions

14 Which nursing intervention is priority for the nursery nurse to complete on a newborn immediately following a cesarean birth?

Suction the newborn's airway

14 A mother tells the nurse that she has been reading a book that says that newborns need stimulation to develop properly and asks what she can do to help her infant. Which tip would not be helpful to the mother?

Swaddling the infant

A new mother tells the postpartum nurse that she thinks her baby does not like her since it cries often when she holds it. How should the nurse respond to this statement?

Tell the mother that it is natural to have feelings of uncertainty when adjusting to a new baby.

14 Which statement is false regarding bathing the newborn?

The bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth.

19 The nurse is caring for a woman who experienced a vaginal birth 6 hours prior. The health care provider is concerned the woman may have retained placental tissue. What assessment finding would alert the nurse to further assess the client for complications of retained placental tissue?

The client's pulse is 130 beats/min at rest and base line was 98 beat/min.

The nurse is looking at the latest lab work for her postpartum client. The client's predelivery hemoglobin and hematocrit (H & H) was 12.8 and 39, respectively. This morning, the client's values are 8.9 and 30. How would the nurse interpret these lab values?

The health care provider needs to be notified of the latest lab values.;

20 The client brings her infant daughter to the pediatrician's office for her first visit since hospital discharge. At birth, the newborn was at the 8th percentile with a weight of 2,350 g. She was born at 36 weeks' gestation. Which documentation is most accurate?

The infant was preterm, low birth weight, and small-for-gestation age neonate.

20 The nurse is caring for a newborn who is large-for-gestational-age (LGA). Which characteristics are documented as a contributing factor? Select all that apply.

The mother has had previous large-for-gestational-age neonates. the mother has poorly controlled diabetes Both parents are of a larger stature and size

20 The nurse is most correct to assess for transient tachypnea of the newborn (TTN) in which neonate?

The neonate delivered by cesarean section

21 The nurse is caring for a neonate with an exstrophy of the bladder. When the nurse is planning care, which client goal is the priority?

The neonate will be free from infection.

14 The nurse has administered erythromycin ointment to a newborn. What outcome indicates this nursing intervention has been effective?

The newborn does not contract ophthalmia neonatorum.

20 Highlight the findings that will require follow-up: Three minutes after birth, a nurse completes a newborn assessment on a newborn birthed at 43 weeks' gestation. The newborn has an APGAR score of 5 at 1 minute. Other assessment findings include green-stained umbilical cord, the presence of acrocyanosis, dry and peeling skin, and the absence of vernix caseosa. Vital signs: temperature,95.9°F (35.5°C). Laboratory values: total bilirubin, 5 mg/dl (85.5 mcmol/l); serum glucose 22 mg/dl (1.22 mmol/).

The newborn has an APGAR score of 5 at 1 minute. Other assessment findings include green-stained umbilical cord, the presence of acrocyanosis, dry and peeling skin, and the absence of vernix caseosa. Vital signs: temperature,95.9°F (35.5°C). Laboratory values: total bilirubin, 5 mg/dl (85.5 mcmol/l); serum glucose 22 mg/dl (1.22 mmol/).

14 The nurse is looking over a newborn's plan of care regarding expected outcomes. Which outcome would not be appropriate according to a newborn's nursing care?

The newborn will experience no bleeding episodes lasting more than 5 minutes. (too long)

20 Which assessment finding within the first 24 hours of birth requires immediate health care provider notification?

The skin is Juandiced

In recording a postpartum mother's urinary output, the nurse notes that she is voiding between 150 and 200 ml with each hourly void. How would the nurse interpret this finding?

The urinary output is normal.

13 What should the nurse expect for a full-term newborn's weight during the first few days of life?

There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns

19 Which instruction would the nurse include in the teaching plan for a postpartum woman with mastitis?

Try applying warm compresses to your breasts to encourage the milk to be released

Which body system is most vulnerable to infection during the postpartum period?

Urinary

14 Following delivery, a newborn has a large amount of mucus coming out of his mouth and nose. What would be the nurse's first action?

Using a bulb syringe, suction the mouth then the nose

13 The nurse is assisting with the assessment of a newborn. What assessment finding indicates that the nurse needs to monitor the newborn's respiratory status further?

Weak cry

14 The experienced RN will intervene if the new graduate is noted to complete which action while caring for newborns?

Wearing artificial nails while caring for multiple newborns

13 At what point should the nurse expect a healthy newborn to pass meconium?

Within 24 hours of birth

A new mother asks the nurse what she is allowed to do when she goes home from the hospital. Which statement by the nurse would be correct?

You should not lift anything heavier than your infant in its carrier.

The nurse is reviewing the health records of several clients who gave birth during the previous shift. For which client would the nurse monitor more frequently for maternal hemorrhage?

a client diagnosed with placenta succenturiate; Placental succenturiate is a concern for maternal hemorrhage if the accessory lobes of the placenta are retained after delivery. The other conditions are not associated with a higher than usual concern for hemorrhage, although all postpartum clients are observed for hemorrhage.

20 A nurse is caring for a newborn who is approximately 13 hours old. On assessment, the nurse notes a yellow tint to the newborn's skin and sclera. What laboratory tests should the nurse anticipate? Select all that apply.

a direct Coombs test A total Bilirubin test a Hemoglobin test

21 The nurse is caring for an infant diagnosed with a ventricular septal defect. Which assessment findings does the nurse anticipate?

a harsh murmur

21 In the infant diagnosed with spina bifida with myelomeningocele, the infant will likely have:

a partial to complete paralysis in the lower extremities.

13 Upon assessing the newborn's respirations, which finding would cause the nurse to notify the HCP?

a respiratory rate of 15 breaths per minute with nasal flaring

20 A nurse is caring for a neonate of 25 weeks' gestation who is at risk for intraventricular hemorrhage (IVH). Which assessment finding should be reported immediately?

a sudden drop in hematocrit

21 The nurse is reviewing the medical record of the antepartum client with an abnormal maternal serum alpha-fetoprotein test. The mother is distraught and states, "How bad can it be?" The nurse is correct to describe which?

a type of spina bifida

21 When examining a newborn for developmental dysplasia of the hip (DDH), which motion would the newborn's hip be unable to accomplish?

abduction

One thing a new mother does is to adapt to the new baby psychologically. The woman takes on her new role as a mother by going through a series of four developmental stages. What is one of them?

achieving a maternal identity

19 A nurse is assessing a postpartum client. Which finding causes the nurse the greatest concern?

acute onset of sharp, stabbing chest pain with shortness of breath

20 After birth, an infant experiences meconium aspiration. What does the nurse anticipate the primary care provider prescribing prophylactically to prevent pneumonia?

antibiotics

The nurse is doing discharge teaching with the parents of a baby. It is their second child. The nurse explains about sibling regression and offers ways to deal with regressive behavior. What is this called?

anticipatory guidance

Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts?

applying ice

19 A postpartum woman is developing a thrombophlebitis in her right leg. Which assessments would the nurse make to detect this?

assess for pedal edema

19 A client who gave birth 5 hours ago has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first?

assess the fundus

19 The nurse is admitting a postpartum client from five days ago with diagnosis of perineal infection. What nursing intervention is most helpful to decrease pain levels from an 8 out of 10 to a 3 out of 10?

assist the client with sitz baths

An adolescent primipara was cautious at first when holding and touching her newborn. She seemed almost afraid to make contact with the baby and only touched it lightly and briefly. However, 48 hours after the birth, the nurse now notices that the new mother is pressing the newborn's cheek against her own and kissing her on the forehead. The nurse recognizes these actions as:

attachment.

20 A late preterm newborn is born at:

between 34 and 37 weeks

19 A nurse is assigned to care for a client with lacerations. The nurse knows that which factor would be the most likely cause of lacerations of the genital tract?

birth of a large newborn

A nurse is monitoring the vital signs of a client 24 hours after birth. She notes that the client's blood pressure is 100/60 mm Hg. Which postpartum complication should the nurse most suspect in this client, based on this finding?

bleeding

14 The nurse is providing care for a 10 lb, 2 oz newborn (4,590 g) who is three hours old. The infant begins to display signs of hypoglycemia. The nurse does a heel stick to obtain the infant's blood glucose level. At which of the following blood glucose levels would the nurse treat the infant for neonatal hypoglycemia?

blood glucose of 35 mg/dl (1.94 mmol/L)

19 Which measurement best describes delayed postpartum hemorrhage?

blood loss in excess of 500 ml, occurring at least 24 hours and up to 12 weeks after birth

When the nurse is assessing a postpartum client approximately 6 hours after birth, which finding would warrant further investigation?

blood pressure 90/50 mm Hg

19 The nurse is caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would the nurse need to assess before the woman ambulates?

blood pressure, pulse, reports of dizziness

19 A postpartal client is receiving heparin as treatment for thrombophlebitis. What should the nurse instruct the client about breastfeeding during this time?

breast feeding can continue

14 The nurse is caring for a newborn immediately following birth. Which body system is priority for the nurse to monitor during the transition phase?

cardiopulmonary

21 In the child diagnosed with hydrocephalus, an obstruction occurs that blocks the normal process of:

cerebrospinal fluid.

19 What postpartum client should the nurse monitor most closely for signs of a postpartum infection?

client who had a non-elective cesarian birth

21 A nurse is performing a newborn assessment and notes the blood pressures in the upper extremities are higher than the lower extremities. The nurse should suspect which congenital newborn abnormality?

coarctation of the aorta

19 One of the primary assessments a nurse makes every day is for postpartum hemorrhage. What does the nurse assess the fundus for?

consistency, shape, and location

20 The nurse is assessing the plantar creases on the newborns for documentation on the Ballard Scale. Which documentation is interpreted as evidence of a full-term infant?

creases covering 2/3 of the anterior foot

20 The nurse is caring for an infant born to a mother with cocaine use disorder during her pregnancy. The nurse would likely notice that this infant:

cries when touched

20 When providing postpartum teaching to a couple, the nurse correctly identifies what time as when pathologic jaundice may be found in the newborn?

during the first 24 hours of life

21 A pregnant client asks the nurse at what point in pregnancy the fetal heart is most susceptible to damage during development. The nurse correctly explains the period as:

during the first 8 weeks of pregnancy when it is forming.

20 At which point is the treatment Rho(D) immune globulin for hemolytic disease of the newborn finished?

during the postpartum period

21 Which assessment findings are most prominent in the infant with tetralogy of Fallot and significant pulmonary stenosis?

dyspnea on limited exertion, fatigue, cyanosis

21 A nurse in the newborn nursery has noticed that an infant is frothing and appears to have excessive drooling. Further assessment reveals that the baby has episodes of respiratory distress with choking and cyanosis. What disorder should the nurse suspect based on these findings?

esophageal atresia

21 The nurse observes a newborn experiencing coughing, choking, and unexplained cyanosis during feeding. These are classic signs of what condition?

esophageal atresia

14 A nurse is teaching new parents how to bathe their newborn once they bring the baby home. Place the body areas listed below in the order that the parents clean the newborn's body. Use all options.

eyes face hair extremities diaper area

21 A nursing student has read that cleft lip is diagnosed at birth based on inspection of physical appearance and that cleft palate is diagnosed by which method?

feeling the palate with a gloved finger or using a tongue blade

The nurse is assessing the fundus of a client on postpartum day 1. What should the nurse expect when palpating the fundus?

fundus one fingerbreadth below umbilicus and firm

21 Following anastomosis repair of a tracheoesophageal fistula, the nurse assesses the infant for which potential complication?

gastroesophageal reflux

20 Which of the following best describes the time between fertilization of the egg and birth?

gestational age

21 The parent of a newborn diagnosed with Turner syndrome asks the nurse about the treatment that will be required for their newborn. Complete the following sentence(s) by choosing from the lists of options. The nurse should educate the parents on the primary treatments used in the treatment of Turner syndrome, which includes _______________ and ________________

growth hormone, estrogen therapy

14 The nursery nurse appropriately identifies which nursing action as most appropriate to prevent neonatal infection?

handwashing

19 A woman who is 2 weeks postpartum calls the clinic and says, "My left breast hurts." After further assessment on the phone, the nurse suspects the woman has mastitis. In addition to pain, the nurse would question the woman about which symptom?

hardening of an area in the infected breast

While observing care being provided to an infant, the new mother looks at the nurse repeatedly and asks, "Am I doing this the right way?" Which nursing diagnosis should the nurse select to guide the care needs of the mother at this time?

health-seeking behaviors related to care of newborn; The new mother is asking the nurse to validate actions being performed while providing newborn care. The nursing diagnosis most appropriate for the new mother at this time would be health-seeking behaviors related to care of the newborn. The new mother is not demonstrating signs of ineffective coping. There is no information to support a risk for altered family coping or risk for impaired parenting.

The nurse is caring for a client is who 24-hours post-delivery of an infant. Which assessment does the nurse predict the health care provider will prioritize for the mother at this time?

hemoglobin and hematocrit

When planning the care for a client during the first 24 hours postpartum, the nurse expects to monitor the client's pulse and blood pressure frequently based on the understanding that the client is at risk for which condition?

hemorrhage

14. The nurse is caring for a newborn with a mother who has a positive hepatitis B surface antigen (HBsAg) test. Which of the following can the nurse expect the newborn to receive? Select all that apply.

hepatitis B vaccination Hepatitis B immune globulin

20 A perinatal nurse is working as a member of a local community health task force to address the impact of substance use during pregnancy. The group is to come up with recommendations for programs that will have a positive impact. After reviewing current research on the topic, on which area(s) will the group likely focus?

heroin alcohol cocaine

21 For which condition would the nurse commonly assess in an infant following surgery for a meningomyelocele?

hydrocephalus

20 The nurse is caring for a newborn with fetal alcohol spectrum disorder. The nurse knows that the newborn will demonstrate:

hyperactivity

20 Newborns born to a mother with diabetes are at risk for which of the following?

hypoglycemia, delayed fetal lung maturity, respiratory distress, and shoulder dystocia

21 During cardiac surgery, the surgeon reduces the child's body temperature to decrease the effects of the surgery on the brain and other body organs. This process is referred to as inducing which of the following?

hypothermia

21 On the second day after a surgical repair for a cleft lip, which of the following would be most important?

preventing crust formation on the suture line

21 A nurse is providing preoperative care to a female newborn client with the congenital abnormality myelomeningocele. Which intervention is the priority?

preventing infection

19 Eight days after birth, the woman notices a return to red lochia. What condition does the nurse anticipate this client is experiencing?

retained placental fragments

The nurse is assessing a client at a postpartum visit. Which hemodynamic change will the nurse expect the client to exhibit?

rise in hematocrit; Hemoglobin and erythrocyte values vary during the early postpartum period, but they should approximate or exceed prelabor values within 2 to 6 weeks. As the woman excretes extracellular fluid, hemoconcentration occurs, with a concomitant rise in hematocrit. Puerperal bradycardia, with rates of 50 to 70 beats per minute, is common during the first 6 to 10 days postpartum. Blood volume decreases following placental separation, contraction of the uterus, and increased stroke volume. Cardiac output begins to increase early in pregnancy and peaks at 20 to 24 weeks' gestation at 30% to 50% above prepregnant levels. Cardiac output decreases during the postpartum period following placental separation, contraction of the uterus, and increased stroke volume.

19 When assessing a client who is 5 days postpartum, which of the following would alert the nurse to suspect that the client is experiencing late postpartum hemorrhage?

rubra colored lochia

A postpartum client comes to the clinic for her 6-week postpartum check up. When assessing the client's cervix, the nurse would expect the external cervical os to appear:

slit-like.

20 Which preventable cause of intrauterine growth restriction (IUGR) is most common?

smoking

Identification of appropriate psychological adaptations to the postpartum period is necessary to detect maladaptive behaviors. Which behavior would indicate the need for further assessment of a new mother's adaptation?

staring off into the distance while holding the newborn

A nurse is caring for a client on her third postpartum day. The nurse identifies a foul-smelling lochia suggesting endometritis. The nurse would also expect to assess an elevation in which of the following?

temperature

20. The registered nurse (RN) is determining a newborn's gestational age. What tool would be best used to evaluate this?

the Ballard scoring system

21 The nurse is providing education to the parents of an infant who was just diagnosed with transposition of the great arteries. The parents ask, "Which vessels were involved?" The nurse is correct to educate about:

the aorta and pulmonary artery.

19 Which situation should concern the nurse treating a postpartum client within a few days of birth?

the client feels empty since she gave birth to the neonate

21 The nurse is caring for a newborn with hydrocephalus. To protect the newborn from injury in the postoperative period, the nurse should position the head:

turned away from the operative site.

Prior to discharge from the hospital, a nurse is checking the fundal height for a new mother who delivered 2 days ago. The nurse would anticipate which finding?

two fingerbreadths below the umbilicus; Immediately after delivery, the uterine fundus should be at the level of the umbilicus. One day postpartum, the height is one fingerbreadth below the umbilicus and by day 2, the fundal height is two fingerbreadths below the umbilicus.

21 The nurse in the newborn nursery is providing shift handoff on a neonate with hydrocephalus. Prior to ventriculoperitoneal shunting, which assessment findings are most important to be communicated? Select all that apply.

type of cry head circumference status of fontanels (fontanelles) projectile vomiting

19 A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition?

uterine atony

19 A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first?

venous duplex ultrasound of the right leg

21 A student nurse is learning about congenital heart defects in newborns and correctly identifies which of the following to be the most common intracardiac defect?

ventricular septal defect

A client is experiencing postpartum hemorrhage and the nurse begins to massage her fundus. Which action would be most appropriate for the nurse to do when massaging the woman's fundus?

wait until the uterus is firm to express clots

19 The nurse is concerned that a postpartum client with a cervical laceration is developing hypovolemic shock. What did the nurse assess in this client?

weak and rapid pulse

The nurse is preparing discharge training for a G2P2 client who will breastfeed her infant. The client mentions she wants more children but wants to wait a couple of years and asks about birth control. Which time frame for using a birth control method should the nurse point out will best help the client achieve her goals?

when she resumes sexual activity

A woman comes to the clinic for her first postpartum visit. She gave birth to a healthy term neonate 2 weeks ago. As part of this visit, the woman has a complete blood count drawn. Which result would the nurse identify as a potential problem?

white blood cell count 14,000/mm3 (14 ×109/L)