HC2B Unit 3 Exam

Postpartum Depression

A new mother's feelings of inadequacy and sadness in the days and weeks after giving birth. May occur at any time during the first postpartum year, typically within the first month

Vernix

A whitish cheese-like substance, covers the fetus while in utero and lubricates the skin of the newborn

A 26-year-old primiparous client is seen in the urgent care clinic 2 weeks after giving birth. The client, who is breastfeeding, is diagnosed with mastitis of the right breast. The client asks the nurse, "Can I continue breastfeeding?" What should the nurse tell the client? A) "You can continue to breastfeed, feeding your baby more frequently." B) "You can continue once your symptoms begin to decrease." C) "You must discontinue breastfeeding until antibiotic therapy is completed." D) "You must stop breastfeeding because the breast is contaminated."

A) "You can continue to breastfeed, feeding your baby more frequently."

At which location would the nurse expect to palpate the fundus of a primiparous client immediately after birth of a neonate? A) Halfway between the umbilicus and the symphysis pubis B) At the level of the umbilicus C) Just below the level of the umbilicus D) Above the level of the umbilicus

A) Halfway between the umbilicus and the symphysis pubis

The nurse provides care for a neonate born two hours ago. Which occurrence initiates changes that take place in the neonate's circulatory system after birth? A) The space constraints of the uterus are removed B) The newborn begins pulmonary ventilation C) The newborn is exposed to excessive sensory stimuli D) The ambient temperature of the newborn is reduced

B) The newborn begins pulmonary ventilation

During a home visit on the fourth postpartum day, a primparous client tells the nurse that she has been experiencing breast engorgement. To relieve engorgement, the nurse teaches the client to use which intervention before nursing her baby? A) Apply an ice cube to the nipples B) Rub the nipples gently with lanolin cream C) Express a small amount of breast milk D) Offer the neonate a small amount of formula

C) Express a small amount of breast milk

Involution

Return of the uterus to a pre-pregnant state after birth

Baby Blues

Transient period of depression that occurs during the first few days of postpartum, usually resolve within 10-14 days

Lochia Alba

WHITE, Continues until cervix is closed

The nurse assess a client, who delivered vaginally 6 days ago, during a home visit. Which finding should the nurse report immediately to the health care provider? SATA. A) Foul-smelling lochia B) Engorged breasts bilaterally C) Client who cries easily D) Soaking 1 peripad every 3-4 hours E) Temperature of 100.8°F

A, E

Scarf Sign

Arm reaching across their chest

A postpartum client gave birth 6 hours ago without anesthesia and just voided 100mL. The nurse palpates the fundus 2 finger-breadths above the umbilicus and off to the right side. What should the nurse do first? A) Administer ibuprofen B) Reassess in 1 hour C) Catheterize the client D) Obtain a prescription for a fluid bolus

C) Catheterize the client

Twelve hours after a vaginal birth with epidural anesthesia, the nurse palpates the fundus of a primiparous client and finds it to be firm, above the umbilicus, and deviated to the right. What should the nurse do next? A) Document this as a normal finding in the client's record B) Contact the health care provider for a prescription for oxytocin C) Encourage the client to ambulate to the bathroom and void D) Gently massage the fundus to expel the clots

C) Encourage the client to ambulate to the bathroom and void

The nurse is caring for a multigravida woman who is 1 day postpartum following a vaginal birth. Which finding indicates a need for further assessment? A) Hemoglobin 12.1 g/dL B) WBC count of 15000 mcL C) Pulse of 60 bpm D) Temperature of 100.8°F

D) Temperature of 100.8°F

At a postpartum checkup 11 days after birth the nurse asks the client about the color of her lochia. Which color is expected? A) Dark red B) Pink C) Brown D) White

D) White

Caput Succedaneum

Diffuse edema of the fetal scalp that crosses the suture lines. Reabsorbs within 12 hours to a few days after birth.

Lochia Serosa

PINK, Day 3-10

Lochia Rubra

RED, First 2-3 days or longer, small clots (nickel size and smaller are normal)

Cephalohematoma

Swelling caused by bleeding between the osteum and periosteum of the skull. This swelling does not cross suture lines.

Mature Milk

The breastmilk after colostrum and transitional milk, typically beginning 2 weeks postpartum, white or slightly blue-tinged color

Acrocyanosis

Blue discoloration of the hands and feet

Which action should the nurse take immediately after the newborn is circumcised? A) Leaves the area open to air B) Diapers the baby with a cloth diaper C) Applies petroleum gauze and observes carefully for bleeding D) Administers prophylactic antibiotics

C) Applies petroleum gauze and observes carefully for bleeding

The nurse palpates the fundus of a client after the third stage of labor. The nurse expects the fundus to have which characteristics? A) Soft and discoid B) Firm and discoid C) Soft and globular D) Firm and globular

D) Firm and globular

A multiparous client visits the urgent care center 5 days after a vaginal birth, experiencing persistent lochia rubra in a moderate to heavy amount. The client asks the nurse, "Why am I continuing to bleed like this?" The nurse should instruct the client that this type of postpartum bleeding is most likely caused by which problem? A) Uterine atony B) Cervical lacerations C) Vaginal lacerations D) Retained placental fragments

D) Retained placental fragments

Square Window Sign

Flexing the newborn's hand towards their forearm

Transitional Milk

Begins 32-96 hours postpartum, may comment "my milk is coming in", light yellow in color but more copious, has more fat, lactose, vitamins, and calories

Lanugo

Fine, soft hair, covers the body and limbs of the fetus or newborn

A breastfeeding client is seen at home by the visiting nurse 10 days after a vaginal birth. The client has a warm, red, painful breast, a temperature of 100°F, and flu-like symptoms. What should the nurse do? A) Encourage the client to breastfeed her infant using the unaffected breast B) Refer the woman to her health care provider C) Inform the client that she needs to discontinue breastfeeding D) Instruct the woman to apply warm compresses to the affected breast

B) Refer the woman to her health care provider

A new parent asks if it is safe to drink wine while breastfeeding. Which is the best response by the nurse? A) "The wine you drink will not be present in the breast milk." B) "A moderate amount of wine will help you relax." C) "Alcohol has a depressant effect on the baby." D) "Drink beer rather than wine while you are breastfeeding."

C) "Alcohol has a depressant effect on the baby."

A multigravid client gave birth vaginally 2 hours ago. A family member notifies the nurse that the client is pale and shaky. Which are the priority assessments for the nurse to make? A) Blood glucose and vital signs B) Temperature and level of consciousness C) Uterine infection and pain D) Fundus and lochia

D) Fundus and lochia

A multiparous client, 28 hours after a cesarean birth, who is breastfeeding has severe cramps or afterpains. The nurse explains that these are caused by which factor? A) Flatulence accumulation after a cesarean birth B) Healing of the abdominal incision after cesarean birth C) Adverse effects of the medications administered after birth D) Release of oxytocin during the breastfeeding session

D) Release of oxytocin during the breastfeeding session

Milia

Exposed sebaceous glands which appear as raised white spots on the face, especially across the nose

The triage nurse in the pediatrician's office returns a call to a mother who is breastfeeding her 4-day-old infant. The mother is concerned about the yellow seedy stool that has developed since discharge home. What is the best reply by the nurse? A) "This type of stool indicates the infant may have diarrhea and should be seen in the office today." B) "The stool will transition into a soft, brown, formed stool within a few days and is appropriate for breastfeeding." C) "The stool results from the gassy food eaten by the mother. Refrain from eating these foods while breastfeeding." D) "Soft, seedy, unformed stools with each feeding are normal for this age infant and will continue through breastfeeding."

D) "Soft, seedy, unformed stools with each feeding are normal for this age infant and will continue through breastfeeding."

The client calls the clinic and complains she does not feel well and has a hard reddened area in one breast. The client is breastfeeding her 2-week-old newborn. Which condition should the nurse understand the client is most likely experiencing? A) Baby Blues B) Primary Engorgement C) Blocked Duct D) Mastitis

D) Mastitis

During the first hour postpartum, an assessment of a multiparous client who gave cesarean birth to a neonate weighing 10 lb, 2 oz reveals a soft fundus with excessive lochia rubra. The nurse should include which interventions in the client's plan of care? A) Administration of IV oxytocin B) Placement of the client in a side-lying position C) Rigorous fundal massage every 5 minutes D) Preparation for an emergency hysterectomy

A) Administration of IV oxytocin

The nurse provides care for a client 24 hours after delivery, and the client states that she has been voiding large amounts of urine. Which response by the nurse is best? A) "You probably have a urinary tract infection." B) "Your body is getting rid of the increased fluid." C) "You must be drinking large amounts of fluid." D) "Your blood glucose is probably elevated."

B) "Your body is getting rid of the increased fluid."

A teen client, who is 1 week postpartum, is concerned about the possibility of postpartum depression because she has a history of depression. Which comment by the client would indicate that she understood the nurse's teaching about the postpartum period and her risks for postpartum depression? A) "Sleep should not be too much of a problem because the baby will soon start to sleep through the night." B) "Since I am breastfeeding, I can eat all the food I want and not feel fat. The baby will use all the calories." C) "If I'm feeling guilty or not capable of caring for the baby an am not sleeping or eating well, I need to contact the office." D) "I'm going to give the baby the best care possible without asking anyone for help to show all those people who think I can't do it."

C) "If I'm feeling guilty or not capable of caring for the baby an am not sleeping or eating well, I need to contact the office."

The nurse provides care for a client six hours after a vaginal delivery and assists the client to perform perineal care. Fifteen minutes later the nurse notes the perineal pad is soaked and there is blood underneath the client's buttocks. Which action does the nurse take first? A) Obtain the client's blood pressure B) Notifies the healthcare provider C) Assesses the fundus D) Administers oxygen at 8-10 L/min

C) Assesses the fundus

A primiparous client who is beginning to breastfeed her neonate asks the nurse, "Is it important for my baby to get colostrum?" When instructing the client, the nurse would explain that colostrum provides the neonate with which factor? A) More fat than breast milk B) Vitamin K, which the neonate lacks C) Delayed meconium passage D) Passive immunity from maternal antibodies

D) Passive immunity from maternal antibodies

A nurse is caring for a client who is 3 days postpartum and breastfeeding her baby. The following assessment is made by the nurse: episiotomy area: red and edematous; breasts: firm and tender on palpation; fundus: firm 2 finger-breadths below umbilicus. What nursing actions are indicated? SATA. A) Suggest the client apply cool compress to breasts B) Encourage the client to sit on supportive diet C) Ask the client how often the baby feeds D) Suggest the client take cool sitz baths twice a day E) Obtain specimen for culture and sensitivity from episiotomy site

A, C

The nurse provides postnatal care for a client diagnosed with gestational diabetes who delivered by cesarean delivery at 37 weeks gestation three hours ago. The infant's APGAR scores were 6 and 8 and birth weight 10 lbs. The client tells the nurse, "I can't believe how big my baby is, and I even delivered early." Which response by the nurse is best? A) "You need to ask your parents if you were a large baby at birth." B) "The baby's large size is due to the amount of glucose received in utero." C) "It is great that you are starting to rely on your maternal instinct already!" D) "You must be relieved that the baby looks so chubby and healthy."

B) "The baby's large size is due to the amount of glucose received in utero."

A multiparous client whose fundus is firm and midline at the umbilicus 8 hours after a vaginal birth tells the nurse that when she ambulated to the bathroom after sleeping for 4 hours, her dark red lochia seemed heavier. Which information would the nurse include when explaining to the client about the increased lochia on ambulation? A) The increased lochia needs to be reported to the health care provider immediately B) The increased lochia occurs from lochia pooling in the vaginal vault C) The increase in lochia may be an early sign of postpartum hemorrhage D) This increase in lochia usually indicates retained placental fragments

B) The increased lochia occurs from lochia pooling in the vaginal vault

During a home visit to a primiparous client who gave birth vaginally 14 days ago, the client says, "I have been crying a lot the past few days. I just feel so awful. I am a rotten mother. I just do not have any energy. Plus, my husband just got laid off from his job." The nurse observes that the client's appearance is disheveled. What would be the nurses best response? A) "These feelings commonly indicate symptoms of postpartum blues and are normal. They will go away in a few days." B) "I think you're probably overreacting to the labor and birth process. You're doing the best you can as a mother." C) "It's not unusual for some mothers to feel depressed after the birth of a baby. I'm going to contact your health care provider." D) "This may be a symptom of a serious mental illness. I think you should probably go to the hospital."

C) "It's not unusual for some mothers to feel depressed after the birth of a baby. I'm going to contact your health care provider."

The nurse instructs a client about dietary adjustments that may be necessary during breastfeeding. Which client statement indicates to the nurse that the client understands the instructions? A) "Dietary changes that enhance weight loss are acceptable." B) "I must drink milk to make milk." C) "There are no specific restrictions on food or drinks." D) "Herbal teas are recommended to enhance milk supply."

C) "There are no specific restrictions on food or drinks."

The nurse makes a home visit to a postpartum client and a two-week-old infant. The client is breastfeeding and tells the nurse the baby nurses 8-9 times per day, has regained all of the lost birth weight, has 6-8 wet diapers per day, and usually has one bowel movement per day. Which response by the nurse is best? A) "Your baby should be gaining more weight." B) "The baby should have at least 3 bowel movements per day." C) "Your baby is doing very well. Keep up the good work." D) "The baby should not need to nurse that frequently."

C) "Your baby is doing very well. Keep up the good work."

A client is in the first hour of her recovery after a vaginal birth. During an assessment, the lochia is moderate, is bright red, and is trickling from the vagina. The nurse locates the fundus at the umbilicus; it is firm and midline with no palpable bladder. The client's vital signs remain at their baseline. Based on this information, the nurse would implement which action? A) Increase the IV rate B) Recheck the admission hematocrit and hemoglobin levels C) Report the findings to the health care provider D) Document the findings as normal

C) Report the findings to the health care provider

The nurse provides instruction to a new parent on how to care for the newborn's umbilical cord. The nurse determines teaching is effective if the parent makes which statement? SATA. A) "I am going to bathe my baby in the new tub tomorrow." B) "I will keep the cord covered with the diaper." C) "I will clean the cord and the skin around it with water." D) "I will allow the cord to fall off on its own." E) "I will expect some redness and discharge at the cord site." F) "I will apply petroleum jelly to the base of the cord."

C, D

A nurse is caring for a woman who gave birth to her baby boy 2 hours ago. The nurse notes that the woman's perineal pad contains some small clots and a moderate amount of lochia has accumulated under her buttocks. What is the first action the nurse should take at this time? A) Request a prescription to administer oxytocin B) Perform an in-and-out catheter immediately C) Measure blood loss by weighing perineal pad D) Check fundus for position and consistency

D) Check fundus for position and consistency

The nurse assesses the fundus of a client twelve hours after delivery of a 7lb 2oz newborn. Which action should the nurse take if the fundus is noted to be approximately 1 cm above the umbilicus? A) Encourage the client to void B) Assess for the amount and character of the lochia C) Bring the infant to the client for breastfeeding D) Document the results in the client's record

D) Document the results in the client's record