Maternal Child Nursing Care: Uncomplicated Postpartum & Newborn (Chapter 18, 19, 20, 22, 23, 24)

The mother of a circumcised infant reports to the nurse that while she is cleaning her child's penis, he cries out loudly. What question does the nurse ask the patient to understand the reason behind this? 1 "Are you applying A&D ointment while cleaning?" 2 "Are you cleaning the penis with lukewarm water?" 3 "Are you applying fresh petrolatum while cleaning?" 4 "Are you cleaning with prepackaged commercial wipes?"

"Are you cleaning with prepackaged commercial wipes?" Do not use prepackaged commercial baby wipes for cleaning the circumcised site because they can contain alcohol. Alcohol delays healing and also causes discomfort to the infant. The infant cries out loudly because of the discomfort. Washing the penis gently with lukewarm water is recommended to remove urine and feces. Fresh petrolatum is applied to reduce pain after each diaper change. The application of A&D ointment while cleaning is done to prevent the sticking of the penis to the discharge, as well as to increase the infant's comfort.

When the infant's behaviors and characteristics call forth a corresponding set of maternal behaviors and characteristics, this is called: a. Mutuality. c. Claiming. b. Bonding. d. Acquaintance.

ANS: A Mutuality extends the concept of attachment to include this shared set of behaviors. Bonding is the process over time of parents forming an emotional attachment to their infant. Mutuality refers to a shared set of behaviors that is a part of the bonding process. Claiming is the process by which parents identify their new baby in terms of likeness to other family members and their differences and uniqueness. Mutuality refers to a shared set of behaviors that is part of the bonding process. Like mutuality, acquaintance is part of attachment. It describes how parents get to know their baby during the immediate postpartum period through eye contact, touching, and talking.

The nurse caring for the newborn should be aware that the sensory system least mature at the time of birth is: a. Vision. c. Smell. b. Hearing. d. Taste.

ANS: A The visual system continues to develop for the first 6 months. As soon as the amniotic fluid drains from the ear (minutes), the infant's hearing is similar to that of an adult. Newborns have a highly developed sense of smell. The newborn can distinguish and react to various tastes.

While assessing the newborn, the nurse should be aware that the average expected apical pulse range of a full-term, quiet, alert newborn is: a. 80 to 100 beats/min. c. 120 to 160 beats/min. b. 100 to 120 beats/min. d. 150 to 180 beats/min.

ANS: C The average infant heart rate while awake is 120 to 160 beats/min. The newborn's heart rate may be about 85 to 100 beats/min while sleeping. The infant's heart rate typically is a bit higher when alert but quiet. A heart rate of 150 to 180 beats/min is typical when the infant cries.

The primary health care provider (PHP) prescribes ventilator support for a newborn. What finding would the PHP have assessed in the newborn?

Bluish discoloration of the skin

4 An offensive odor usually indicates an infection. Lochia flow should approximate a heavy menstrual period for the first 2 hours and then steadily decrease. Less lochia usually is seen after cesarean births. Lochia usually increases with ambulation and breastfeeding.

Postbirth uterine/vaginal discharge (called lochia): 1 is similar to a light menstrual period for the first 6 to 12 hours. 2 is usually greater after cesarean births. 3 will usually decrease with ambulation and breastfeeding. 4 should smell like normal menstrual flow unless an infection is present.

3 If a patient with excessive postpartum hemorrhage shows signs such as grayish, cool, and clammy skin, the patient is at risk of developing hypovolemic shock. If the patient has foul-smelling lochia, then the patient might be at risk of infection. Every patient experiences pain after giving birth; however, a change in skin color does not result from pain. If the patient has not voided urine within 8 hours after birth, then the patient might be at risk of impaired urinary elimination.

The nurse is caring for a patient with excessive postpartum hemorrhage. The nurse observes that the patient's skin has turned grayish. What does the nurse infer from this finding? 1 Risk of infection 2 Evidence of severe pain 3 Potential risk of hypovolemic shock 4 Potential risk of impaired urinary elimination

A newborn is placed under a radiant heat warmer, and the nurse evaluates the infant's body temperature every hour. Maintaining the newborn's body temperature is important for preventing: a. Respiratory depression. c. Tachycardia. b. Cold stress. d. Vasoconstriction.

ANS: B Loss of heat must be controlled to protect the infant from the metabolic and physiologic effects of cold stress, and that is the primary reason for placing a newborn under a radiant heat warmer. Cold stress results in an increased respiratory rate and vasoconstriction.

What marks on a baby's skin may indicate an underlying problem that requires notification of a physician? a. Mongolian spots on the back b. Telangiectatic nevi on the nose or nape of the neck c. Petechiae scattered over the infant's body d. Erythema toxicum anywhere on the body

ANS: C Petechiae (bruises) scattered over the infant's body should be reported to the pediatrician because they may indicate underlying problems. Mongolian spots are bluish-black spots that resemble bruises but fade gradually over months and have no clinical significance. Telangiectatic nevi (stork bites, angel kisses) fade by the second year and have no clinical significance. Erythema toxicum is an appalling-looking rash, but it has no clinical significance and requires no treatment.

While examining a newborn, the nurse notes uneven skin folds on the buttocks and a click when performing the Ortolani maneuver. The nurse recognizes these findings as a sign that the newborn probably has: a. Polydactyly. c. Hip dysplasia. b. Clubfoot. d. Webbing

ANS: C The Ortolani maneuver is used to detect the presence of hip dysplasia. Polydactyly is the presence of extra digits. Clubfoot (talipes equinovarus) is a deformity in which the foot turns inward and is fixed in a plantar-flexion position. Webbing, or syndactyly, is a fusing of the fingers or toes.

The student nurse is asked to distinguish cutaneous jaundice from normal skin color of a neonate. What will the student nurse do to differentiate them?

Apply pressure on the forehead with a finger

4 While learning to breastfeed, women may refrain from talking or smiling excessively so that the infant will not be distracted and will continue to feed. The patient does not avoid talking to soothe and quiet the infant; instead, she may gently stroke the infant to provide comfort after feeding. Avoiding speaking with the infant is not helpful for coping with depression and is not a typical behavior of postpartum blues. The mother's quiet behavior during breastfeeding does not indicate that she has not properly bonded with the baby.

The nurse observes that a postpartum patient does not talk or smile during breastfeeding but instead quietly maintains her gaze on the infant. What does the nurse infer from this observation? The patient: 1 Aims to soothe and quiet the infant. 2 Is experiencing postpartum blues. 3 Is not properly bonding with the infant. 4 Wants the infant to suck the milk without interruption.

3 A high pulse rate of 129 beats per minute in a postpartum patient immediately after childbirth may be indicative of hypovolemia caused by blood loss during labor. This is an abnormal assessment finding postdelivery. Labor may cause dehydration, and this may result in a slight increase in body temperature of up to 38° C. This is a normal finding associated with labor. Blood pressure may be slightly altered after childbirth. A blood pressure of 126/80 mm Hg would be a normal finding in this patient. The respiratory rate increases during labor and then slowly comes back to normal after labor. Normal respiratory rate is 12 to 14 breaths per minute. Thus, 15 breaths per minute is a normal finding.

Which postpartum patient finding would the nurse consider abnormal when assessing the patient's vital signs immediately after childbirth? 1 Temperature 38° C 2 Blood pressure 126/80 mm Hg 3 Pulse rate 129 beats per minute 4 Respiratory rate 15 breaths per minute

Following circumcision of a newborn, the nurse provides instructions to his or her parents regarding postcircumcision care. The nurse should tell the parents to: 1 apply topical anesthetics with each diaper change. 2 expect a yellowish exudate to cover the glans after the first 24 hours. 3 change the diaper every 2 hours and cleanse the site with soap and water or baby wipes. 4 apply constant pressure to the site if bleeding occurs and call the physician

expect a yellowish exudate to cover the glans after the first 24 hours Parents should be taught that a yellow exudate will develop over the glans and should not be removed. Topical anesthetics are applied before the circumcision. Infant-comforting techniques are generally sufficient following the procedure. The diaper is changed frequently, but the site is cleansed with warm water only because soap and baby wipes can cause pain/burning and irritation at the site. Intermittent pressure is applied if bleeding occurs.

When placing a newborn under a radiant heat warmer to stabilize the temperature after birth, the nurse should: 1 place the thermistor probe on the left side of the chest. 2 cover the probe with a nonreflective material. 3 recheck the temperature by periodically taking a rectal temperature. 4 prewarm the radiant heat warmer and place the undressed newborn under it.

prewarm the radiant heat warmer and place the undressed newborn under it. The radiant warmer should be prewarmed so the infant does not experience more cold stress. The thermistor probe should be placed on the upper abdomen away from the ribs. It should be covered with reflective material. Rectal temperatures should be avoided because rectal thermometers can perforate the intestine, and the temperature may remain normal until cold stress is advanced.

The nurse is taking care of a newborn. The nurse finds out that the infant weighs 1800 g and the mother's HBsAg status is unknown. When should the nurse administer the hepatitis B immune globulin (HGIB) vaccine to the infant? 1 9 hours after the infant is born 2 13 hours after the infant is born 3 14 hours after the infant is born 4 18 hours after the infant is born

9 hours after the infant is born If the mother's HBsAg status is unknown, then the infant's weight is considered to determine the time for the administration of the HBIG vaccine. The infant weighs 1800 g, so the HBIG vaccine is given within 12 hours after the infant's birth. Therefore the HBIG vaccine should be administered 9 hours after birth, not 13, 14, or 18 hours after. If the mother's HBsAg status is known and the baby weighs more than 2000 g, then the HBIG vaccine can be administered within a week of the newborn's birth. In such a situation, the vaccine can be administered at 13, 14, or 18 hours after the birth of the infant.

The nurse is assessing a neonate with hydrocephaly. What observation reported by the nurse would be consistent with the neonate's condition?

A head circumference greater than chest circumference Hydrocephaly is a condition where fluids accumulate around the neonate's brain. Hydrocephaly is confirmed when the neonate's head circumference is 4.5 cm greater than the chest circumference. If a neonate has a body weight of 7 pounds, it is the normal weight of a newborn and does not indicate any abnormalities. A neonatal heart rate with 120 beats/min indicates that the newborn is healthy. A head-to-heel length of 55 cm is the normal body length of any newborn. This factor does not lead to hydrocephaly.

3 The recommended caloric intake for a lactating mother who breastfeeds more than one infant is more than 2700 kcal/day. If a lactating mother of twins takes less than 2200 kcal/day, she may not produce enough milk. An intake of 1800 to 2200 kcal/day is recommended for nonlactating mothers.

A lactating patient who gave birth to twins 1 month earlier approaches the primary health care provider (PHP) for a general checkup. What suggestion does the nurse give to the patient about the recommended calorie intake? 1 Less than 1800 kcal/day 2 Less than 2200 kcal/day 3 More than 2700 kcal/day 4 Should be 1800 to 2200 kcal/day

3 Increased frequency of urination in a postpartum patient is termed postpartal diuresis. Postpartum patients have decreased estrogen and progesterone levels. In addition, removal of increased venous pressure in the lower extremities and loss of the remaining pregnancy-induced increase in blood volume may also cause diuresis. Diuresis helps get rid of excess fluids from the body. The levels of oxytocin are not related to postpartum diuresis. The aldosterone levels drop after childbirth and are not related to postpartum diuresis. hCG tends to disappear after the childbirth and has no role in diuresis.

A lactating postpartum patient reports frequent urination. What could be the reason for increased frequency of urination in the patient? A decrease in the levels of: 1 Estrogen and aldosterone 2 Oxytocin and progesterone 3 Progesterone and estrogen 4 Human chorionic gonadotropin (hCG)

3 In the immediate puerperium, a decrease in the levels of human placental lactogen, estrogens, and cortisol is seen. This results in significantly lowered blood glucose levels. Therefore it is a transitional period for carbohydrate metabolism, making it difficult to interpret the glucose tolerance test. Breastfeeding the baby gradually depletes the mother's energy stores deposited during the pregnancy and does not have a significant influence on the glucose tolerance. Blood, tissue debris, fluids, and retained fragments of membranes are discharged out in the form of lochia, which does not affect the glucose tolerance test. Dietary regulations prevent the mother from consuming additional calories, but this does not influence the glucose tolerance of the woman in her immediate puerperium.

A lactating woman with type 1 diabetes in her immediate puerperium period undergoes a glucose tolerance test. The test results are nonconclusive. What could be the reason for the test to be nonconclusive? 1 Breastfeeding the baby 2 Loss of blood in the form of lochia 3 Decreased levels of maternal hormones 4 Decreased food intake and diet regulations

2 The depressed phase after pregnancy and delivery is known as postpartum blues, or "baby blues," where the mother may experience restlessness, insomnia, and headache. Episiotomy would cause other symptoms related to pain, such as restlessness and insomnia, but it would not cause the mother to experience headaches. The pink phase of the postpartum period is the period where the woman experiences a sense of heightened joy and feelings of well-being. Anesthesia is not given during vaginal delivery, so this is not a factor in her postpartum symptoms.

A mother who had a vaginal delivery reports being restless and having insomnia and regular episodes of headache 4 days after childbirth. What would the nurse infer about the mother's clinical condition from these symptoms? The mother: 1 Is experiencing pain from the episiotomy. 2 Likely has postpartum blues. 3 Is in the pink postpartum period. 4 Was given spinal anesthesia during the delivery process.

1, 4, 5 The nonlactating patient may feel discomfort caused by the accumulation of milk. The nurse advises the patient to use ice packs, fresh cabbage leaves, and a well-fitted supportive bra for relieving discomfort. The nurse should not advise the patient to express milk or perform nipple stimulation because it increases milk production, which worsens pain and discomfort.

A nonbreastfeeding patient reports discomfort in the breast caused by the accumulation of milk. What should the nurse suggest to the patient to relieve the discomfort? Select all that apply. 1 "Use ice packs on the breast." 2 "Express the breast milk." 3 "Perform nipple stimulation." 4 "Apply fresh cabbage leaves on breast." 5 "Use a well-fitted supportive bra."

2 Lochial bleeding is normal and decreases with time. Nonlochial bleeding occurs as a result of the tears in either the cervical or vaginal regions. In normal condition (lochial), the bleeding decreases with time. However, in this patient there is continuous bleeding even 4 weeks after childbirth. Normally, the color of the blood is bright red in the beginning (known as lochia rubra); after that, the color of the blood becomes slightly less pigmented. Therefore the patient has nonlochial discharge evident by the continuous bright red color bleeding. The odor of the lochia is the same as of the menstrual bleeding. The offensive odor of the lochia indicates presence of infection.

A patient reports continuous bleeding 4 weeks after childbirth. Upon assessment, the nurse finds that the bleeding is bright red in color with an offensive odor. What does the nurse suspect as the cause of the bleeding? 1 Lochial; the odor is caused by infection. 2 Nonlochial; the odor is caused by infection. 3 Lochial; the odor is normal in all postpartum patients. 4 Nonlochial; the odor is normal in all postpartum patients.

1, 2, 3 The patient reports having problems with lactation. Thus the nurse should assist in establishing and maintaining a successful breastfeeding process for the patient. To do this, the nurse should teach the patient about the infant's rooting and sucking reflexes. The patient should be asked to immediately breastfeed the child after birth. Then the nurse has to explain frequent milk expression and kangaroo care to the patient for optimized milk supply. Placing the newborn skin-to-skin with the parent immediately after birth is not useful for breastfeeding. The nurse has to talk to the patient about the infant's capabilities for interaction while teaching the patient how to nurture the infant in the first year of life, but these interventions are not in response to problems with lactation.

A patient reports having difficulty ejecting milk while breastfeeding the infant. Which nursing interventions would help the patient breastfeed the newborn with greater ease? Select all that apply. 1 Teach the patient about the infant's rooting and sucking reflexes. 2 Ask the patient to breastfeed the newborn immediately after birth. 3 Explain frequent milk expression and kangaroo care to the patient. 4 Talk to the patient about the newborn's capabilities for interaction. 5 Ensure the newborn has good contact with the patient immediately after birth.

1 After birth uterine discharge is commonly called lochia that accumulates in the vagina when the woman is lying down. This comes out as a gush of blood when the woman assumes an upright position. If the lochia has a strong smell, it may indicate an offensive odor; this patient does not report an offensive odor. During the assessment, the nurse does not find any symptoms associated with hemorrhage, such as increased heart rate or low blood pressure. Dyspareunia is associated with coital discomfort.

A patient reports to the nurse that she has bright red discharge 3 days after delivery. The patient tells the nurse that a gush of blood comes out of her vagina upon standing upright. What should the nurse interpret from the assessment? 1 Normal finding after delivery 2 Dyspareunia 3 Infection 4 Hemorrhage

2, 5 A patient who has had a cesarean birth and has remained in the bed for more than 8 hours is at risk of venous thromboembolism. If a thrombus is suspected, as evidenced by warmth, redness, or tenderness in the leg, the nurse should notify the PHP immediately. Meanwhile, the patient should remain in bed with the affected limb elevated on pillows. Applying heat increases discomfort because the affected limb is already warm. Applying antiinflammatory ointment to the leg at the reddened site would not be useful because the redness is caused by embolism, not inflammation.

A patient who has had a cesarean birth has been on bed rest for 8 hours after surgery and has warmth and redness in the left lower limb. Which interventions taken by the nurse would be most beneficial to the patient? Select all that apply. 1 Advise the patient to apply a hot compress at the reddened site. 2 Inform the primary health care provider (PHP) about the patient's condition immediately. 3 Advise the patient to apply an antiinflammatory ointment at the reddened site. 4 Have the patient sit upright and lower the reddened leg. 5 Have the patient remain in bed with reddened limb elevated on pillows.

1 If the patient reports severe perineal pain after vaginal delivery, the nurse should apply ice packs in the first 24 hours to reduce edema, pain, and vulvar irritation. Administering fluids and blood compensates for blood loss in the patient, but they do not reduce pain. Postpartum hematologic studies are performed to assess the consequences of blood loss. This intervention does not reduce pain in the patient.

A patient who underwent a vaginal delivery 3 hours earlier reports having severe perineal pain. Which would be the first step taken by the nurse in this situation? 1 Apply ice packs in the perineum. 2 Administer fluids to the patient. 3 Administer blood to the patient. 4 Refer the patient for hematologic tests.

2, 3, 4 Persistent headache in postpartum patients need to be evaluated further. However, the stress and physical fatigue of childbirth may cause the patient to experience headaches. Postpartum-onset preeclampsia, characterized by high blood pressure and the presence of proteins in the urine, may also cause headaches. Epidural or spinal anesthesia involves the placement of the needle into the spinal space. This may lead to leakage of cerebrospinal fluid into the extradural space, resulting in a headache. Orthostatic hypotension may cause dizziness, but it does not cause headache. The presence of varices and hemorrhoids may cause discomfort and pain, but these do not cause headache.

A postpartum patient complains of a headache. What could be the reasons for the headache in the patient? Select all that apply. 1 Orthostatic hypotension 2 Stress of childbirth in the patient 3 Postpartum-onset preeclampsia 4 Leakage of the cerebrospinal fluid 5 Presence of varices and hemorrhoids

3, 4, 5 Patients who choose not to breastfeed may experience breast engorgement and related discomfort. The nurse should instruct the patient to wear a well-fitted support bra or use a breast binder to support the breasts, which can relieve discomfort. Applying ice packs with a 15-minutes-on, 45-minutes-off schedule also helps relieve breast engorgement and reduce discomfort. Expressing milk from the breast or performing nipple stimulation may increase milk production and may worsen breast engorgement.

A postpartum patient has chosen not to breastfeed. What instructions should the nurse provide to the patient to prevent discomfort caused by breast engorgement? Select all that apply. 1 Express the milk from both breasts. 2 Perform regular breast stimulation. 3 Wear a well-fitted support bra. 4 Use a breast binder. 5 Apply ice packs on the breasts

1 The patient who has an episiotomy may have constipation due to discomfort during bowel movements. Therefore the nurse should instruct the patient to use stool softeners to help ease the passage of stools. Prenatal vitamins should be continued in all patients regardless of the episiotomy. All patients should take iron supplements to increase their hemoglobin levels. However, they do not ease the discomfort of episiotomy. Analgesics are usually prescribed for patients who underwent a cesarean.

A postpartum patient who has an episiotomy is being discharged to home. Which instruction about medications is most important for the patient? 1 Take stool softeners regularly. 2 Continue prenatal vitamins. 3 Include iron supplements. 4 Take analgesics as prescribed.

4 Fingernails may regain strength to the prepregnancy state in a few weeks after delivery. Brittle and soft nails are caused by iron deficiency, not potassium deficiency. Carpal tunnel syndrome causes physiologic edema due to compression of the median nerve, but it does not cause brittle and soft nails. Moisture can cause soft and brittle fingers, so moisture should be reduced, not enhanced.

A pregnant patient reports to the nurse, "My nails are soft and brittle, and I am worried about it." What is the nurse's best response to the patient? 1 "You should make sure your nails are well moisturized." 2 "You have low potassium, so take potassium supplements." 3 "Your nails are soft and brittle due to carpal tunnel syndrome." 4 "After delivery your nails should return to normal consistency and strength."

2 Women express a need to review their childbirth experience and evaluate their performance. After the mother's needs are met, she is more able to take an active role, not only in her own care but also in the care of her newborn. Short teaching sessions (using written materials to reinforce the content presented) are a more effective approach. The focus of the taking-in stage is nurturing the new mother by meeting her dependency needs for rest, comfort, hygiene, and nutrition. Test-Taking Tip: After choosing an answer, go back and reread the question stem along with your chosen answer. Does it fit correctly? The choice that grammatically fits the stem and contains the correct information is the best choice.

A primiparous woman is in the taking-in stage of psychosocial recovery and adjustment following birth. Recognizing the needs of women during this stage, the nurse should: 1 foster an active role in the baby's care. 2 provide time for the mother to reflect on the events of and her behavior during childbirth. 3 recognize the woman's limited attention span by giving her written materials to read when she gets home rather than doing a teaching session now. 4 promote maternal independence by encouraging her to meet her own hygiene and comfort needs.

2 Dyspareunia is a condition of painful sexual intercourse, which results in localized dryness and coital discomfort. This is commonly seen in the woman after childbirth and is due to decreased estrogen levels, vaginal dryness, or poor lubrication of the vagina. Therefore it is usually recommended to use a water-soluble lubricant during sexual intercourse. Hemorrhoids are the enlarged veins in the anus or lower rectum that cause itching, discomfort, and bright red bleeding upon defecation. However, these are not known to cause dyspareunia. There are many foldings inside the vagina, known as rugae, which reappear within 3 weeks after childbirth. However, these foldings do not cause dyspareunia. If the woman does not practice good hygiene and health, erythema and edema may persist in the introitus, especially in the area of laceration repair.

A woman complains of dyspareunia during the involution process. What does the nurse suspect to be the cause of dyspareunia? 1 Hemorrhoids 2 Estrogen deficiency 3 Foldings in the vagina 4 Poor hygiene and health

4 After childbirth, the abdominal wall is relaxed, so the abdomen protrudes similarly to the pregnancy state. This condition usually takes 6 weeks to return to a prepregnant state. Reducing fat content in the diet may help reduce weight. However, in postpartum patients, the protruding abdomen results from increased elasticity in the uterus and cannot be reduced by reducing fat in the diet. Vigorous exercise should not be prescribed immediately after delivery, because the patient would still be in a fragile state. Breastfeeding would help utilize the fat deposited during the pregnancy, but it does not reduce a protruding abdomen.

A worried postpartum patient reports to the nurse, "It's been 3 weeks after my delivery, and I am still showing." Which is the best response of the nurse? 1 "Reduce the fat content in your diet; it will help you." 2 "Start a vigorous exercise routine, and you will be fine." 3 "Breastfeeding the child will reduce the protruding abdomen." 4 "Three more weeks and you will most likely be back to an almost prepregnant state."

The cheeselike, whitish substance that fuses with the epidermis and serves as a protective coating is called: a. Vernix caseosa c. Caput succedaneum b. Surfactant d. Acrocyanosis

ANS: A This protection, vernix caseosa, is needed because the infant's skin is so thin. Surfactant is a protein that lines the alveoli of the infant's lungs. Caput succedaneum is the swelling of the tissue over the presenting part of the fetal head. Acrocyanosis is cyanosis of the hands and feet, resulting in a blue coloring.

A first-time father is changing the diaper of his 1-day-old daughter. He asks the nurse, "What is this black, sticky stuff in her diaper?" The nurse's best response is: a. "That's meconium, which is your baby's first stool. It's normal." b. "That's transitional stool." c. "That means your baby is bleeding internally." d. "Oh, don't worry about that. It's okay."

ANS: A "That's meconium, which is your baby's first stool. It's normal" is an accurate statement and the most appropriate response. Transitional stool is greenish brown to yellowish brown and usually appears by the third day after initiation of feeding. "That means your baby is bleeding internally" is not accurate. "Oh, don't worry about that. It's okay" is not an appropriate statement. It is belittling to the father and does not educate him about the normal stool patterns of his daughter.

A client is warm and asks for a fan in her room for her comfort. The nurse enters the room to assess the mother and her infant and finds the infant unwrapped in his crib with the fan blowing over him on "high." The nurse instructs the mother that the fan should not be directed toward the newborn and the newborn should be wrapped in a blanket. The mother asks why. The nurse's best response is: a. "Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him." b. "Your baby may lose heat by conduction, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him." c. "Your baby may lose heat by evaporation, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him." d. "Your baby will get cold stressed easily and needs to be bundled up at all times."

ANS: A "Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him" is an accurate statement. Conduction is the loss of heat from the body surface to cooler surfaces, not air, in direct contact with the newborn. Evaporation is loss of heat that occurs when a liquid is converted into a vapor. In the newborn heat loss by evaporation occurs as a result of vaporization of moisture from the skin. Cold stress may occur from excessive heat loss, but this does not imply that the infant will become stressed if not bundled at all times. Furthermore, excessive bundling may result in a rise in the infant's temperature

With regard to the functioning of the renal system in newborns, nurses should be aware that: a. The pediatrician should be notified if the newborn has not voided in 24 hours. b. Breastfed infants likely will void more often during the first days after birth. c. "Brick dust" or blood on a diaper is always cause to notify the physician. d. Weight loss from fluid loss and other normal factors should be made up in 4 to 7 days.

ANS: A A newborn who has not voided in 24 hours may have any of a number of problems, some of which deserve the attention of the pediatrician. Formula-fed infants tend to void more frequently in the first 3 days; breastfed infants void less during this time because the mother's breast milk has not come in yet. Brick dust may be uric acid crystals; blood spotting could be caused by withdrawal of maternal hormones (pseudomenstruation) or a circumcision. The physician must be notified only if there is no apparent cause of bleeding. Weight loss from fluid loss might take 14 days to regain.

A new mother states that her infant must be cold because the baby's hands and feet are blue. The nurse explains that this is a common and temporary condition called: a. Acrocyanosis. c. Harlequin color. b. Erythema neonatorum. d. Vernix caseosa.

ANS: A Acrocyanosis, or the appearance of slightly cyanotic hands and feet, is caused by vasomotor instability, capillary stasis, and a high hemoglobin level. Acrocyanosis is normal and appears intermittently over the first 7 to 10 days. Erythema toxicum (also called erythema neonatorum) is a transient newborn rash that resembles flea bites. The harlequin sign is a benign, transient color change in newborns. Half of the body is pale, and the other half is ruddy or bluish red with a line of demarcation. Vernix caseosa is a cheeselike, whitish substance that serves as a protective covering.

New parents express concern that, because of the mother's emergency cesarean birth under general anesthesia, they did not have the opportunity to hold and bond with their daughter immediately after her birth. The nurse's response should convey to the parents that: a. Attachment, or bonding, is a process that occurs over time and does not require early contact. b. The time immediately after birth is a critical period for people. c. Early contact is essential for optimum parent-infant relationships. d. They should just be happy that the infant is healthy.

ANS: A Attachment, or bonding, is a process that occurs over time and does not require early contact. The formerly accepted definition of bonding held that the period immediately after birth was a critical time for bonding to occur. Research since has indicated that parent-infant attachment occurs over time. A delay does not inhibit the process. Parent-infant attachment involves activities such as touching, holding, and gazing; it is not exclusively eye contact. A response that conveys that the parents should just be happy that the infant is healthy is inappropriate because it is derogatory and belittling.

A collection of blood between the skull bone and its periosteum is known as a cephalhematoma. To reassure the new parents whose infant develops such a soft bulge, it is important that the nurse be aware that this condition: a. May occur with spontaneous vaginal birth. b. Only happens as the result of a forceps or vacuum delivery. c. Is present immediately after birth. d. Will gradually absorb over the first few months of life.

ANS: A Bleeding may occur during a spontaneous vaginal delivery as a result of the pressure against the maternal bony pelvis. The soft, irreducible fullness does not pulsate or bulge when the infant cries. Low forceps and other difficult extractions may result in bleeding. However, these can also occur spontaneously. The swelling may appear unilaterally or bilaterally and is usually minimal or absent at birth. It increases over the first 2 to 3 days of life. Cephalhematomas disappear gradually over 2 to 3 weeks. A less common condition results in calcification of the hematoma, which may persist for months.

Part of the health assessment of a newborn is observing the infant's breathing pattern. A full-term newborn's breathing pattern is predominantly: a. Abdominal with synchronous chest movements. b. Chest breathing with nasal flaring. c. Diaphragmatic with chest retraction. d. Deep with a regular rhythm.

ANS: A In normal infant respiration the chest and abdomen rise synchronously, and breaths are shallow and irregular. Breathing with nasal flaring is a sign of respiratory distress. Diaphragmatic breathing with chest retraction is a sign of respiratory distress. Infant breaths are not deep with a regular rhythm

The nurse can help a father in his transition to parenthood by: a. Pointing out that the infant turned at the sound of his voice. b. Encouraging him to go home to get some sleep. c. Telling him to tape the infant's diaper a different way. d. Suggesting that he let the infant sleep in the bassinet.

ANS: A Infants respond to the sound of voices. Because attachment involves a reciprocal interchange, observing the interaction between parent and infant is very important. Separation of the parent and infant does not encourage parent-infant attachment. Educating the parent in infant care techniques is important, but the manner in which a diaper is taped is not relevant and does not enhance parent-infant interactions. Parent-infant attachment involves touching, holding, and cuddling. It is appropriate for a father to want to hold the infant as the baby sleeps.

The nurse notes that a Vietnamese woman does not cuddle or interact with her newborn other than to feed him, change his diapers or soiled clothes, and put him to bed. In evaluating the woman's behavior with her infant, the nurse realizes that: a. What appears to be a lack of interest in the newborn is in fact the Vietnamese way of demonstrating intense love by attempting to ward off evil spirits. b. The woman is inexperienced in caring for newborns. c. The woman needs a referral to a social worker for further evaluation of her parenting behaviors once she goes home with the newborn. d. Extra time needs to be planned for assisting the woman in bonding with her newborn.

ANS: A The nurse may observe a Vietnamese woman who gives minimal care to her infant and refuses to cuddle or interact with her infant. The apparent lack of interest in the newborn is this cultural group's attempt to ward off evil spirits and actually reflects an intense love and concern for the infant. It is important to educate the woman in infant care, but it is equally important to acknowledge her cultural beliefs and practices.

In the United States the en face position is preferred immediately after birth. Nurses can facilitate this process by all of these actions except: a. Washing both the infant's face and the mother's face. b. Placing the infant on the mother's abdomen or breast with their heads on the same plane. c. Dimming the lights. d. Delaying the instillation of prophylactic antibiotic ointment in the infant's eyes.

ANS: A To facilitate the position in which the parent's and infant's faces are approximately 8 inches apart on the same plane, allowing them to make eye contact, the nurse can place the infant at the proper height on the mother's body, dim the light so that the infant's eyes open, and delay putting ointment in the infant's eyes.

With regard to the respiratory development of the newborn, nurses should be aware that: a. The first gasping breath is an exaggerated respiratory reaction within 1 minute of birth. b. Newborns must expel the fluid from the respiratory system within a few minutes of birth. c. Newborns are instinctive mouth breathers. d. Seesaw respirations are no cause for concern in the first hour after birth.

ANS: A The first breath produces a cry. Newborns continue to expel fluid for the first hour of life. Newborns are natural nose breathers; they may not have the mouth-breathing response to nasal blockage for 3 weeks. Seesaw respirations instead of normal abdominal respirations are not normal and should be reported.

What concerns about parenthood are often expressed by visually impaired mothers? Choose all that apply. a. Infant safety b. Transportation c. The ability to care for the infant d. Missing out visually e. Needing extra time for parenting activities to accommodate the visual limitations

ANS: A, B, D, E Concerns expressed by visually impaired mothers include infant safety, extra time needed for parenting activities, transportation, handling other people's reactions, providing proper discipline, and missing out visually. Blind people sense reluctance on the part of others to acknowledge that they have a right to be parents. However, blind parents are fully capable of caring for their infants.

Many first-time parents do not plan on their parents' help immediately after the newborn arrives. What statement by the nurse is the most appropriate when counseling new parents about the involvement of grandparents? a. "You should tell your parents to leave you alone." b. "Grandparents can help you with parenting skills and also help preserve family traditions." c. "Grandparent involvement can be very disruptive to the family." d. "They are getting old. You should let them be involved while they can."

ANS: B "Grandparents can help you with parenting skills and also help preserve family traditions" is the most appropriate response. Intergenerational help may be perceived as interference, but a statement of this sort is not therapeutic to the adaptation of the family. Not only is "Grandparent involvement can be very disruptive to the family" invalid, it also is not an appropriate nursing response. Regardless of age, grandparents can help with parenting skills and preserve family traditions. Talking about the age of the grandparents is not the most appropriate statement, and it does not demonstrate sensitivity on the part of the nurse.

The parents of a newborn ask the nurse how much the newborn can see. The parents specifically want to know what type of visual stimuli they should provide for their newborn. The nurse responds to the parents by telling them: a. "Infants can see very little until about 3 months of age." b. "Infants can track their parent's eyes and distinguish patterns; they prefer complex patterns." c. "The infant's eyes must be protected. Infants enjoy looking at brightly colored stripes." d. "It's important to shield the newborn's eyes. Overhead lights help them see better."

ANS: B "Infants can track their parent's eyes and distinguish patterns; they prefer complex patterns" is an accurate statement. Development of the visual system continues for the first 6 months of life. Visual acuity is difficult to determine, but the clearest visual distance for the newborn appears to be 19 cm. Infants prefer to look at complex patterns, regardless of the color. Infants prefer low illumination and withdraw from bright light.

The transition period between intrauterine and extrauterine existence for the newborn: a. Consists of four phases, two reactive and two of decreased responses. b. Lasts from birth to day 28 of life. c. Applies to full-term births only. d. Varies by socioeconomic status and the mother's age.

ANS: B Changes begin right after birth; the cutoff time when the transition is considered over (although the baby keeps changing) is 28 days. The transition period has three phases: first reactivity, decreased response, and second reactivity. All newborns experience this transition regardless of age or type of birth. Although stress can cause variation in the phases, the mother's age and wealth do not disturb the pattern.

In follow-up appointments or visits with parents and their new baby, it may be useful if the nurse can identify parental behaviors that can either facilitate or inhibit attachment. What is a facilitating behavior? a. The parents have difficulty naming the infant. b. The parents hover around the infant, directing attention to and pointing at the infant. c. The parents make no effort to interpret the actions or needs of the infant. d. The parents do not move from fingertip touch to palmar contact and holding.

ANS: B Hovering over the infant and obviously paying attention to the baby are facilitating behaviors. Inhibiting behaviors include difficulty naming the infant, making no effort to interpret the actions or needs of the infant, and not moving from fingertip touch to palmar contact and holding.

Other early sensual contacts between infant and mother involve sound and smell. Nurses should be aware that, despite what folk wisdom might say: a. High-pitched voices irritate newborns. b. Infants can learn to distinguish their mother's voice from others soon after birth. c. All babies in the hospital smell alike. d. A mother's breast milk has no distinctive odor.

ANS: B Infants know the sound of their mother's voice early. Infants respond positively to high-pitched voices. Each infant has a unique odor. Infants quickly learn to distinguish the odor of their mother's breast milk.

When dealing with parents who have some form of sensory impairment, nurses should realize that all of these statements are true except: a. One of the major difficulties visually impaired parents experience is the skepticism of health care professionals. b. Visually impaired mothers cannot overcome the infant's need for eye-to-eye contact. c. The best approach for the nurse is to assess the parents' capabilities rather than focusing on their disabilities. d. Technologic advances, including the Internet, can provide deaf parents with a full range of parenting activities and information.

ANS: B Other sensory output can be provided by the parent, other people can participate, and other coping devices can be used. The skepticism, open or hidden, of health care professionals places an additional and unneeded hurdle for the parents. After the parents' capabilities have been assessed (including some the nurse may not have expected), the nurse can help find ways to assist the parents that play to their strengths. The Internet affords an extra teaching tool for the deaf, as do videos with subtitles or nurses signing. A number of electronic devices can turn sound into light flashes to help pick up a child's cry. Sign language is acquired readily by young children.

The nurse observes that a 15-year-old mother seems to ignore her newborn. A strategy that the nurse can use to facilitate mother-infant attachment in this mother is to: a. Tell the mother she must pay attention to her infant. b. Show the mother how the infant initiates interaction and pays attention to her. c. Demonstrate for the mother different positions for holding her infant while feeding. d. Arrange for the mother to watch a video on parent-infant interaction.

ANS: B Pointing out the responsiveness of the infant is a positive strategy for facilitating parent-infant attachment. Telling the mother that she must pay attention to her infant may be perceived as derogatory and is not appropriate. Educating the young mother in infant care is important, but pointing out the responsiveness of her baby is a better tool for facilitating mother-infant attachment. Videos are an educational tool that can demonstrate parent-infant attachment, but encouraging the mother to recognize the infant's responsiveness is more appropriate.

With regard to the adaptation of other family members, mainly siblings and grandparents, to the newborn, nurses should be aware that: a. Sibling rivalry cannot be dismissed as overblown psychobabble; negative feelings and behaviors can take a long time to blow over. b. Participation in preparation classes helps both siblings and grandparents. c. In the United States paternal and maternal grandparents consider themselves of equal importance and status. d. Since 1990 the number of grandparents providing permanent care to their grandchildren has been declining.

ANS: B Preparing older siblings and grandparents helps with everyone to adapt. Sibling rivalry should be expected initially, but the negative behaviors associated with it have been overemphasized and stop in a comparatively short time. In the United States, in contrast to other cultures, paternal grandparents frequently consider themselves secondary to maternal grandparents. The number of grandparents providing permanent child care has been rising.

An examiner who discovers unequal movement or uneven gluteal skin folds during the Ortolani maneuver would then: a. Tell the parents that one leg may be longer than the other, but they will equal out by the time the infant is walking. b. Alert the physician that the infant has a dislocated hip. c. Inform the parents and physician that molding has not taken place. d. Suggest that, if the condition does not change, surgery to correct vision problems might be needed.

ANS: B The Ortolani maneuver is a technique for checking hip integrity. Unequal movement suggests that the hip is dislocated. The physician should be notified.

By knowing about variations in infants' blood count, nurses can explain to their clients that: a. A somewhat lower than expected red blood cell count could be the result of delay in clamping the umbilical cord. b. The early high white blood cell (WBC) count is normal at birth and should decrease rapidly. c. Platelet counts are higher than in adults for a few months. d. Even a modest vitamin K deficiency means a problem with the ability of the blood to clot properly.

ANS: B The WBC count is high the first day of birth and then declines rapidly. Delayed clamping of the cord results in an increase in hemoglobin and the red blood cell count. The platelet count essentially is the same for newborns and adults. Clotting is sufficient to prevent hemorrhage unless the vitamin K deficiency is significant.

A woman gave birth to a healthy 7-pound, 13-ounce infant girl. The nurse suggests that the woman place the infant to her breast within 15 minutes after birth. The nurse knows that breastfeeding is effective during the first 30 minutes after birth because this is the: a. Transition period. c. Organizational stage. b. First period of reactivity. d. Second period of reactivity.

ANS: B The first period of reactivity is the first phase of transition and lasts up to 30 minutes after birth. The infant is highly alert during this phase. The transition period is the phase between intrauterine and extrauterine existence. There is no such phase as the organizational stage. The second period of reactivity occurs roughly between 4 and 8 hours after birth, after a period of prolonged sleep.

The nurse observes several interactions between a postpartum woman and her new son. What behavior, if exhibited by this woman, would the nurse identify as a possible maladaptive behavior regarding parent-infant attachment? a. Talks and coos to her son b. Seldom makes eye contact with her son c. Cuddles her son close to her d. Tells visitors how well her son is feeding

ANS: B The woman should be encouraged to hold her infant in the en face position and make eye contact with the infant. Normal infant-parent interactions include talking and cooing to her son, cuddling her son close to her, and telling visitors how well her son is feeing.

1. What are modes of heat loss in the newborn? Choose all that apply. a. Perspiration b. Convection c. Radiation d. Conduction e. Urination

ANS: B, C, D Convection, radiation, evaporation, and conduction are the four modes of heat loss in the newborn. Perspiration and urination are not modes of heat loss in newborns.

Of the many factors that influence parental responses, nurses should be aware that all of these statements regarding age are true except: a. An adolescent mother's egocentricity and unmet developmental needs interfere with her ability to parent effectively. b. An adolescent mother is likely to use less verbal instruction, be less responsive, and interact less positively than other mothers. c. Adolescent mothers have a higher documented incidence of child abuse. d. Mothers older than 35 often deal with more stress related to work and career issues and decreasing libido.

ANS: C Adolescent mothers are more inclined to have a number of parenting difficulties that benefit from counseling, but a higher incidence of child abuse is not one of them. Midlife mothers have many competencies but are more likely to have to deal with career and sexual issues than are younger mothers.

With regard to the gastrointestinal (GI) system of the newborn, nurses should be aware that: a. The newborn's cheeks are full because of normal fluid retention. b. The nipple of the bottle or breast must be placed well inside the baby's mouth because teeth have been developing in utero, and one or more may even be through. c. Regurgitation during the first day or two can be reduced by burping the infant and slightly elevating the baby's head. d. Bacteria are already present in the infant's GI tract at birth, because they traveled through the placenta.

ANS: C Avoiding overfeeding can also reduce regurgitation. The newborn's cheeks are full because of well-developed sucking pads. Teeth do develop in utero, but the nipple is placed deep because the baby cannot move food from the lips to the pharynx. Bacteria are not present at birth, but they soon enter through various orifices.

The nurse hears a primiparous woman talking to her son and telling him that his chin is just like his dad's chin. This woman's statement reflects: a. Mutuality. c. Claiming. b. Synchrony. d. Reciprocity.

ANS: C Claiming refers to the process by which the child is identified in terms of likeness to other family members. Mutuality occurs when the infant's behaviors and characteristics call forth a corresponding set of maternal behaviors and characteristics. Synchrony refers to the "fit" between the infant's cues and the parent's responses. Reciprocity is a type of body movement or behavior that provides the observer with cues.

During a phone follow-up conversation with a woman who is 4 days' postpartum, the woman tells the nurse, "I don't know what's wrong. I love my son, but I feel so let down. I seem to cry for no reason!" The nurse would recognize that the woman is experiencing: a. Taking-in. c. Postpartum (PP) blues. b. Postpartum depression (PPD). d. Attachment difficulty.

ANS: C During the PP blues women are emotionally labile, often crying easily and for no apparent reason. This lability seems to peak around the fifth PP day. The taking-in phase is the period after birth when the mother focuses on her own psychologic needs. Typically this period lasts 24 hours. PPD is an intense, pervasive sadness marked by severe, labile mood swings; it is more serious and persistent than the PP blues. Crying is not a maladaptive attachment response; it indicates PP blues

While assessing the integument of a 24-hour-old newborn, the nurse notes a pink, papular rash with vesicles superimposed on the thorax, back, and abdomen. The nurse should: a. Notify the physician immediately. b. Move the newborn to an isolation nursery. c. Document the finding as erythema toxicum. d. Take the newborn's temperature and obtain a culture of one of the vesicles.

ANS: C Erythema toxicum (or erythema neonatorum) is a newborn rash that resembles flea bites. This is a normal finding that does not require notification of the physician, isolation of the newborn, or any additional interventions

With regard to parents' early and extended contact with their infant and the relationships built, nurses should be aware that: a. Immediate contact is essential for the parent-child relationship. b. Skin-to-skin contact is preferable to contact with the body totally wrapped in a blanket. c. Extended contact is especially important for adolescents and low-income women because they are at risk for parenting inadequacies. d. Mothers need to take precedence over their partners and other family matters.

ANS: C Nurses should encourage any activity that optimizes family extended contact. Immediate contact facilitates the attachment process but is not essential; otherwise, adopted infants would not establish the affectionate ties they do. The mode of infant-mother contact does not appear to have any important effect. Mothers and their partners are considered equally important.

The early postpartum period is a time of emotional and physical vulnerability. Many mothers can easily become psychologically overwhelmed by the reality of their new parental responsibilities. Fatigue compounds these issues. Although the baby blues are a common occurrence in the postpartum period, about one-half million women in America experience a more severe syndrome known as postpartum depression (PPD). Which statement regarding PPD is essential for the nurse to be aware of when attempting to formulate a nursing diagnosis? a. PPD symptoms are consistently severe. b. This syndrome affects only new mothers. c. PPD can easily go undetected. d. Only mental health professionals should teach new parents about this condition.

ANS: C PPD can go undetected because parents do not voluntarily admit to this type of emotional distress out of embarrassment, fear, or guilt. PPD symptoms range from mild to severe, with women having both good and bad days. Both mothers and fathers should be screened. PPD in new fathers ranges from 1% to 26%. The nurse should include information on PPD and how to differentiate this from the baby blues for all clients on discharge. Nurses also can urge new parents to report symptoms and seek follow-up care promptly if they occur

With regard to the newborn's developing cardiovascular system, nurses should be aware that: a. The heart rate of a crying infant may rise to 120 beats/min. b. Heart murmurs heard after the first few hours are cause for concern. c. The point of maximal impulse (PMI) often is visible on the chest wall. d. Persistent bradycardia may indicate respiratory distress syndrome (RDS).

ANS: C The newborn's thin chest wall often allows the PMI to be seen. The normal heart rate for infants who are not sleeping is 120 to 160 beats/min. However, a crying infant temporarily could have a heart rate of 180 beats/min. Heart murmurs during the first few days of life have no pathologic significance; an irregular heart rate past the first few hours should be evaluated further. Persistent tachycardia may indicate RDS; bradycardia may be a sign of congenital heart blockage.

During life in utero oxygenation of the fetus occurs through transplacental gas exchange. When birth occurs, four factors combine to stimulate the respiratory center in the medulla. The initiation of respiration then follows. Which is NOT one of these essential factors? a. Chemical c. Thermal b. Mechanical d. Psychologic

ANS: D A psychologic factor is not one of the essential factors in the initiation of breathing; the fourth factor is sensory. The sensory factors include handling by the provider, drying by the nurse, lights, smells, and sounds. Chemical factors are essential for the initiation of breathing. During labor decreased levels of oxygen and increased levels of carbon dioxide seem to have a cumulative effect that is involved in the initiation of breathing. Clamping of the cord may also contribute to the start of respirations. Prostaglandins are known to inhibit breathing. Clamping of the cord results in a drop in the level of prostaglandins. Mechanical factors also are necessary to initiate respirations. As the infant passes through the birth canal, the chest is compressed. With birth the chest is relaxed, which allows for negative intrathoracic pressure that encourages air to flow into the lungs. The profound change in temperature between intrauterine and extrauterine life stimulates receptors in the skin to communicate with the receptors in the medulla. This also contributes to the initiation of breathing

Nursing activities that promote parent-infant attachment are many and varied. One activity that should not be overlooked is the management of the environment. While providing routine mother-baby care, the nurse should ensure that: a. The baby is able to return to the nursery at night so that the new mother can sleep. b. Routine times for care are established to reassure the parents. c. The father should be encouraged to go home at night to prepare for mother-baby discharge. d. An environment that fosters as much privacy as possible should be created.

ANS: D Care providers need to knock before gaining entry. Nursing care activities should be grouped. Once the baby has demonstrated adjustment to extrauterine life (either in the mother's room or the transitional nursery), all care should be provided in one location. This important principle of family-centered maternity care fosters attachment by giving parents the opportunity to learn about their infant 24 hours a day. One nurse should provide care to both mother and baby in this couplet care or rooming-in model. It is not necessary for the baby to return to the nursery at night. In fact, the mother will sleep better with the infant close by. Care should be individualized to meet the parents' needs, not the routines of the staff. Teaching goals should be developed in collaboration with the parents. The father or other significant other should be permitted to sleep in the room with the mother. The maternity unit should develop policies that allow for the presence of significant others as much as the new mother desires.

An African-American woman noticed some bruises on her newborn girl's buttocks. She asks the nurse who spanked her daughter. The nurse explains that these marks are called: a. Lanugo. c. Nevus flammeus. b. Vascular nevi. d. Mongolian spots.

ANS: D A Mongolian spot is a bluish black area of pigmentation that may appear over any part of the exterior surface of the body. It is more commonly noted on the back and buttocks and most frequently is seen on infants whose ethnic origins are Mediterranean, Latin American, Asian, or African. Lanugo is the fine, downy hair seen on a term newborn. A vascular nevus, commonly called a strawberry mark, is a type of capillary hemangioma. A nevus flammeus, commonly called a port-wine stain, is most frequently found on the face.

All of these statements about physiologic jaundice are true except: a. Neonatal jaundice is common, but kernicterus is rare. b. The appearance of jaundice during the first 24 hours or beyond day 7 indicates a pathologic process. c. Because jaundice may not appear before discharge, parents need instruction on how to assess it and when to call for medical help. d. Breastfed babies have a lower incidence of jaundice.

ANS: D Breastfeeding is associated with an increased incidence of jaundice. Neonatal jaundice occurs in 60% of newborns; the complication called kernicterus is rare. Jaundice in the first 24 hours or that persists past day 7 is cause for medical concern. Parents need to know how to assess jaundice.

After giving birth to a healthy infant boy, a primiparous woman, 16, is admitted to the postpartum unit. An appropriate nursing diagnosis for her at this time is risk for impaired parenting related to deficient knowledge of newborn care. In planning for the woman's discharge, what should the nurse be certain to include in the plan of care? a. Tell the woman how to feed and bathe her infant. b. Give the woman written information on bathing her infant. c. Advise the woman that all mothers instinctively know how to care for their infants. d. Provide time for the woman to bathe her infant after she views an infant bath demonstration.

ANS: D Having the mother demonstrate infant care is a valuable method of assessing the client's understanding of her newly acquired knowledge, especially in this age group, because she may inadvertently neglect her child. Although verbalizing how to care for the infant is a form of client education, it is not the most developmentally appropriate teaching for a teenage mother. Although providing written information is useful, it is not the most developmentally appropriate teaching for a teenage mother. Advising the woman that all mothers instinctively know how to care for their infants is an inappropriate statement; it is belittling and false

While evaluating the reflexes of a newborn, the nurse notes that with a loud noise the newborn symmetrically abducts and extends his arms, his fingers fan out and form a "C" with the thumb and forefinger, and he has a slight tremor. The nurse would document this finding as a positive: a. Tonic neck reflex. c. Babinski reflex. b. Glabellar (Myerson) reflex. d. Moro reflex.

ANS: D The characteristics displayed by the infant are associated with a positive Moro reflex. The tonic neck reflex occurs when the infant extends the leg on the side to which the infant's head simultaneously turns. The glabellar reflex is elicited by tapping on the infant's head while the eyes are open. A characteristic response is blinking for the first few taps. The Babinski reflex occurs when the sole of the foot is stroked upward along the lateral aspect of the sole and then across the ball of the foot. A positive response occurs when all the toes hyperextend, with dorsiflexion of the big toe.

All of these statements describe the first phase of the transition period except: a. It lasts no longer than 30 minutes. b. It is marked by spontaneous tremors, crying, and head movements. c. It includes the passage of meconium. d. It may involve the infant suddenly sleeping briefly.

ANS: D The first phase is an active phase in which the baby is alert. Decreased activity and sleep mark the second phase. The first phase is the shortest, lasting less than 30 minutes. Such exploratory behaviors include spontaneous startle reactions. In the first phase the newborn also produces saliva.

The nurse assessing a newborn knows that the most critical physiologic change required of the newborn is: a. Closure of fetal shunts in the circulatory system. b. Full function of the immune defense system at birth. c. Maintenance of a stable temperature. d. Initiation and maintenance of respirations.

ANS: D The most critical adjustment of a newborn at birth is the establishment of respirations. The cardiovascular system changes markedly after birth as a result of fetal respiration, which reduces pulmonary vascular resistance to the pulmonary blood flow and initiates a chain of cardiac changes that support the cardiovascular system. The infant relies on passive immunity received from the mother for the first 3 months of life. After the establishment of respirations, heat regulation is critical to newborn survival.

After birth a crying infant may be soothed by being held in a position in which the newborn can hear the mother's heartbeat. This phenomenon is known as: a. Entrainment. c. Synchrony. b. Reciprocity. d. Biorhythmicity.

ANS: D The newborn is in rhythm with the mother. The infant develops a personal biorhythm with the parents' help over time. Entrainment is the movement of newborns in time to the structure of adult speech. Reciprocity is body movement or behavior that gives cues to the person's desires. These take several weeks to develop with a new baby. Synchrony is the fit between the infant's behavioral cues and the parent's responses.

What infant response to cool environmental conditions is either NOT effective or NOT available to them? a. Constriction of peripheral blood vessels b. Metabolism of brown fat c. Increased respiratory rates d. Unflexing from the normal position

ANS: D The newborn's flexed position guards against heat loss because it reduces the amount of body surface exposed to the environment. The newborn's body is able to constrict the peripheral blood vessels to reduce heat loss. Burning brown fat generates heat. The respiratory rate may rise to stimulate muscular activity, which generates heat.

One reason the brain is vulnerable to nutritional deficiencies and trauma in early infancy is the: a. Incompletely developed neuromuscular system. b. Primitive reflex system. c. Presence of various sleep-wake states. d. Cerebellum growth spurt.

ANS: D The vulnerability of the brain likely is to the result of the cerebellum growth spurt. The neuromuscular system is almost completely developed at birth. The reflex system is not relevant. The various sleep-wake states are not relevant.

Upon assessing the CRIES neonatal postoperative pain scale findings, the nurse concludes that the infant is experiencing severe pain. What finding made the nurse conclude this? Incorrect1 The infant wakes up frequently. 2 The infant's skin has a pink complexion. Correct3 The infant requires 40% oxygen support. 4 The infant's Heart rate was 110 beats/min.

According to the CRIES scale, the infant is experiencing severe pain when he or she requires more than 30% oxygen support to maintain normal functioning. The normal heart rate of an infant is 110 beats/min. The heart rate increases when the infant cries. A pink complexion is a normal indication, so a pink complexion does not cause the nurse to conclude that the infant is in severe pain.

2 Most postpartum women often experience a "blue" period 2 days after childbirth, during which women may be emotional and cry for no explainable reason. This is called postpartum blues and is the natural hormonal reaction after giving birth. The nurse may instruct the patient to soak in a tub for 20 minutes on a regular basis to promote relaxation and help the patient cope with the postpartum blues. Postpartum women do not typically have trouble staying warm, so this is not the reason for the nurse's suggestion. Soaking in the tub does not facilitate eye contact, so the nurse would more likely encourage the mother to hold the baby en face position if this were the problem.

After assessing a postpartum patient 2 days after childbirth, the nurse instructs the patient to soak in a warm water tub for 20 minutes every day. What is the most likely reason for this instruction? The patient: 1 Is unable to stay warm. 2 Cries easily for no apparent reason. 3 Is joyful and has a feeling of well-being. 4 Has trouble maintaining direct eye contact with the infant.

The nurse administers concentrated oral sucrose through the suckling method to a neonate before performing the heelstick method. Why would the nurse do this?

As a source of comfort to the infant The heelstick method is used to collect blood to estimate various biologic and chemical materials. The nurse administers oral sucrose to a neonate before performing a painful procedure such as the heelstick method to comfort the neonate. It is not necessary to hydrate the neonate before performing the heelstick method. Hydration of a neonate is usually achieved by administering human milk or infant formula. The infant's glucose levels are maintained by infusing dextrose; it is not used to recognize reflexes in infant.

1, 5 Breasts are essentially unchanged for the first 24 hours after birth. Colostrum, or early milk, a clear, yellow fluid, may be expressed from the breasts during the first 24 hours. Leakage of milk occurs after the milk comes in 72 to 96 hours after birth. Engorgement occurs at day 3 or 4 postpartum. A few blisters and a bruise indicate problems with the breastfeeding techniques being used.

As part of postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding woman who is 1-day postpartum. Expected findings include: Select all that apply. 1 little if any change. 2 leakage of milk at let-down. 3 swollen, warm, and tender on palpation. 4 a few blisters and a bruise on each areola. 5 small amount of clear, yellow fluid expressed

The nurse auscultates a neonate in resting position and hears a murmur. What further assessments should the nurse make to know if the infant has any cardiac defects?

Assess BP in all 4 extremities When murmurs are heard, the nurse should check the neonates' BP from all four extremities to rule out congenital heart diseases. Circumference of the head is measured to detect head-related complications, such as microcephaly and hydrocephaly. However, it is unrelated to congenital heart disease. Assessing the body movements would correlate more with the muscular activity of the neonate but not with cardiac activity.

A mother expresses fear about changing her infant's diaper after he is circumcised. What does the woman need to be taught to take care of the infant when she gets home?

Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change

The mother of a newborn reports that the baby scratches himself with his long nails. What would the nurse suggest to the mother? Select all that apply. 1 Clip the baby's nails every day. 2 Cut the nails while the baby is playing. 3 Cut the nails while the baby is sleeping. 4 Cut the nails while breastfeeding the baby. 5 Cover the baby's hands with loose-fitting mitts

Clip the baby's nails every day, Cut the nails while the baby is sleeping, Cover the baby's hands with loose-fitting mitts Cover the baby's hands with loose-fitting mitts. The nurse suggests that the mother cut the baby's nails when the baby is sleeping. Covering the hands of the baby with loose-fitting mitts would protect the baby from scratching himself. Since the nails do not grow very fast, it is not necessary to cut them daily. The infant's nails should not be cut while playing, because it may disturb the movement of extremities and could cause injuries to the fingers. Cutting the nails while the baby is breastfeeding is also not recommended, because it disturbs the feeding infant.

1 The appealing facial expression of the infant is a normal behavioral pattern and is indicative of the infant's desire to seek the parents' attention. If the infant seeks attention from other adults, it indicates that the infant is not getting required attention from the parents. Jerky movements upon touching indicate that the infant is not reacting in a normal way to the parents and may suggest that the parents are not comfortable while handling the infant. If the infant does not respond properly to the care giving tasks of the parents, it indicates that the infant lacks adequate attachment with the parents.

During a home visit, the nurse observes that a newborn baby is well attached to the parents. Which infant behavior did the nurse most likely observe in the baby? 1 The baby used appealing facial expressions. 2 The baby sought attention from other adults. 3 The baby's body movements were jerky when touched. 4 The baby was unresponsive to the parents' caregiving.

2, 4 After the baby's birth, the patient feels irritated and stressed due to lack of sleep. The nurse should suggest interventions that help the patient rest. For example, if the patient's family can be called upon to help with the household chores while the patient looks after the baby and rests, this can help the patient feel more relaxed in the early days of parenting. The patient should try to adjust her schedule to nap when the baby sleeps if possible. Installing bright lights is not an effective technique, as it does not promote sleep. Organizing a dinner party may increase the number of visitors and guests in the home, which, in turn, can increase the household work, causing the patient to become even more fatigued and tired. Coffee contains caffeine and may cause insomnia by stimulating the central nervous system (CNS). Therefore, drinking coffee 3 times a day does not support relaxation.

During the postnatal visit, the patient tells the nurse, "I'm feeling irritated and tired. I haven't slept properly for days." The nurse suggests a few interventions to help the patient with relaxation and rest. Which techniques adopted by the patient indicate effective learning? Select all that apply. 1 Installed bright lights in the room 2 Asked a family member to stay overnight 3 Organized a small dinner party at her home 4 Takes a nap when the baby is sleeping 5 Started drinking coffee 3 times a day

3 Uterine atony can best be thwarted by maintaining good uterine tone and preventing bladder distention. Although vaginal or vulvar hematomas are a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause. Although unrepaired lacerations are a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause. Although retained placental fragments is a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause.

Excessive blood loss after childbirth can have several causes; however, the most common is: 1 vaginal or vulvar hematomas. 2 unrepaired lacerations of the vagina or cervix. 3 failure of the uterine muscle to contract firmly. 4 retained placental fragments.

During assessment, the nurse finds that the heart rate of a neonate is 110 beats/min and respiratory rates vary from 35 to 40 breaths/min. The nurse also finds that the neonate has a pink complexion. What conclusion regarding the Apgar score would the nurse make from these findings? The neonate:

Exhibits normal findings

4 Mothers need to reestablish their own well-being to effectively care for their baby. The woman should not be told what to do and needs to care for her own well-being. Because the woman needs to rest does not indicate ineffective maternal-newborn attachment. The behavior described is typical of this stage and is not a reflection of ineffective attachment unless it persists. Test-Taking Tip: Be alert for grammatical inconsistencies. If the response is intended to complete the stem (an incomplete sentence) but makes no grammatical sense to you, it might be a distractor rather than the correct response. Question writers typically try to eliminate these inconsistencies.

Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just wants to sleep. The nurse should: 1 tell the woman she can rest after she feeds her baby. 2 recognize this as a behavior of the taking-hold stage. 3 record the behavior as ineffective maternal-newborn attachment. 4 take the baby back to the nursery, reassuring the woman that her rest is a priority at this time.

The nurse gives a newborn an Apgar score of 4. What condition observed in the neonate would be consistent with the score? 1 Clear eyes 2 Acrocyanosis 3 Flexed posture 4 Heart rate of 70 beats/min

Heart rate of 70 beats/min The Apgar score of 4 indicates that the neonate has difficulty adapting to the extrauterine environment. A heart rate of 70 beats/min is not a normal finding and can be consistent with the condition. Observations such as clear eyes, acrocyanosis, and flexed posture in the neonate are normal findings and suggest an Apgar score of 7 to 10. However, these findings are not consistent with the low Apgar score of 4.

The nurse is assessing a breastfed newborn 1 hour after birth. The nurse identified that the glucose levels are less than 25 mg/dL and immediately reported it to the primary health care provider (PHP). What medication administration does the nurse expect the PHP to advise?

IV dextrose infusion

After assessing an infant's health screening reports, the nurse instructs the mother to stop breastfeeding and switch to a soy-based formula. What findings most likely caused the nurse to recommend this change? 1 Elevated leucine levels in the infant 2 Increased galactose levels in the infant 3 Elevated methionine levels in the infant 4 Increased thyrotropin levels in the infant

Increased galactose levels in the infant Galactosemia is a condition where the galactose levels are elevated in an infant. If this condition is present, the nurse would instruct the mother to stop breastfeeding, because breast milk is contraindicated in infants with galactosemia. Elevated leucine causes maple syrup urine disease in an infant but is not a contraindication for breastfeeding. Elevated methionine causes homocystinuria in infants who are supplemented with thiamine. Elevated thyrotropin, or elevated thyroid-stimulating hormone (TSH), causes congenital hypothyroidism in infants. The parents of infants suffering from congenital hypothyroidism are instructed to get the newborn's bone mass tested regularly.

The nurse is assessing an infant with a body weight of 2500 g. Two days after delivery the blood report of the infant's mother confirms the presence of hepatitis B. What medication does the primary health care provider instruct the nurse to administer to the infant? 1 Intravenous (I.V.) hepatitis B vaccine 2 Intramuscular (IM) hepatitis B vaccine 3 Intravenous (I.V.) hepatitis B immune globulin (HBIG) 4 Intramuscular (IM) hepatitis B immune globulin (HBIG)

Intramuscular (IM) hepatitis B immune globulin (HBIG) A dose of IM HBIG should be given to the infant whose mother's hepatitis B surface antigen's (HBsAg) status is determined to be positive. The vaccine is also given to infants who weigh 2000 g or more before 1 week of age. The hepatitis B vaccine and HBIG are not given through the IV route in infants because of their adverse effects. The IM hepatitis B vaccine is given to infants born to hepatitis B surface antigen (HBsAg)-negative mothers before being discharged from the hospital.

The nurse observes increased bilirubin levels in the laboratory reports of a newborn. Which complication does the nurse expect in the newborn if this condition is poorly monitored? Syndactyly 2 Kernicterus 3 Rectal fistula 4 Down syndrome

Kernicterus Very high levels of bilirubin cause kernicterus. Bilirubin is a yellow pigment that is produced in the body during the normal recycling of old red blood cells (RBCs). High levels of bilirubin in the body can cause the skin to look yellow, a condition known as jaundice. Syndactyly is a condition where two or more digits are fused together. It is not associated with increased bilirubin levels. Rectal fistula is caused by the absence of the anal opening in the newborn. Down syndrome is a chromosome defect and is not associated with increased bilirubin levels.

4 Homans' sign is an assessment test used to determine whether the patient has VTE. Presence of Homans' sign indicates that the patient may have VTE. Uterine atony can be assessed by palpating the uterine fundus. Hypotensive shock can be assessed by checking the patient's vitals. Mastitis can be assessed by the examining the patient's breasts.

On reviewing the medical reports of a postpartum patient, the nurse finds that the patient has Homans' sign. What does the nurse interpret from this finding? 1 Risk of uterine atony 2 Hypotensive shock 3 Risk of developing mastitis 4 Venous thromboembolism (VTE)

1 Having the sibling make or choose a gift for the new baby helps to make the child feel a part of the process. Special time should be set aside just for the other children without interruption from the newborn. Someone other than the mother should carry the baby into the home so she can give full attention to greeting her other children. Children should be actively involved in the care of the baby according to their ability without overwhelming them.

Parents can facilitate the adjustment of their other children to a new baby by: 1 having the children choose or make a gift to give to the new baby on its arrival home. 2 emphasizing activities that keep the new baby and other children together. 3 having the mother carry the new baby into the home so she can show him or her to the other children. 4 reducing stress on other children by limiting their involvement in the care of the new baby.

4 The peribottle should be used in a backward direction over the perineum . The flow should never be directed upward into the vagina because debris would be forced upward into the uterus through the still-open cervix. Using soap and warm water to wash is appropriate. Washing from the symphysis pubis back to the episiotomy is appropriate. Changing the perineal pad every 2 to 3 hours is appropriate. STUDY TIP: When forming a study group, carefully select members for your group. Choose students who have abilities and motivation similar to your own. Look for students who have a different learning style than you. Exchange names, email addresses, and phone numbers. Plan a schedule for when and how often you will meet. Plan an agenda for each meeting. You may exchange lecture notes and discuss content for clarity or quiz one another on the material. You could also create your own practice tests or make flash cards that review key vocabulary terms.

Perineal care is an important infection control measure. When evaluating a postpartum woman's perineal care technique, the nurse recognizes the need for additional instruction if the woman: 1 uses soap and warm water to wash the vulva and perineum. 2 washes from the symphysis pubis back to the episiotomy. 3 changes her perineal pad every 2 to 3 hours. 4 uses the peribottle to rinse upward into her vagina.

The nurse is assessing a preterm baby and observes dark red skin color with harlequin signs on the skin. What does the nurse infer from these findings? The baby has: Hypotension. 2 Polycythemia. 3 Hyperthermia. 4 A neurologic disorder

Polycythemia - Polycythemia is common in preterm infants because of the presence of fetal red blood cells (RBCs) The dark red color skin of the newborn with harlequin signs indicates polycythemia. Polycythemia is common in preterm infants because of the presence of fetal red blood cells (RBCs). The presence of hypotension in the infant is indicated by gray coloration of the skin. The presence of hyperthermia in a newborn is indicated by blue coloration (cyanosis) of the skin. Neurologic disorders are associated with cyanosis but not with polycythemia

The nurse is educating the parents of a newborn about the use of the bulb syringe. Which statement from the parents indicates effective learning about the bulb syringe? "It is used in the baby to:

Prevent suffocation and clear airway obstruction The bulb syringe is used to prevent suffocation and clear airway obstruction of newborns, and hence, it prevents aspiration. If the newborn's anal opening prevents defecation, it leads to severe gastrointestinal abnormalities. The bulb syringe is not used to reduce the newborn's temperature during hypothermia. It is also not used to avoid heat loss from the newborn due to evaporation and convection. Heat loss from the newborn is avoided by using warm water for bathing, drying the newborn carefully, and avoiding exposing the newborn to drafts.

The nurse is assessing a neonate who was born on the way to hospital. Which nursing intervention should be performed to prevent apneic spells in the neonate? 1 Provide warmth to the neonate. 2 Provide ventilator support to the neonate. 3 Provide chest compressions to the neonate. 4 Clean the neonate's body with lukewarm water

Provide warmth to the neonate. The neonate born on the way to hospital may become hypothermic, so the nurse should gradually warm the neonate's body to avoid apneic spells (insufficiency breathing). Rapid warming may cause apneic spells. Thus the warming process should be gradual. Ventilator or chest compressions are given when a neonate already has respiratory distress, which is identified by assessing the heart rate. The nurse can use lukewarm water to clear the stains on the neonate's body only after thermal stability is achieved.

The nurse evaluates the blood pressure (BP) of a neonate and suspects a cardiac defect. What recordings of the neonate's BP confirm a cardiac defect? 1 The BP in the lower extremities is 60/40 mm Hg and in the upper extremities is 70/50 mm Hg. Correct2 The BP in the lower extremities is 50/40 mm Hg and in the upper extremities is 80/70 mm Hg. Incorrect3 The BP in the lower extremities is 70/40 mm Hg and in the upper extremities is 60/40 mm Hg. 4 The BP in the lower extremities is 80/40 mm Hg and in the upper extremities is 70/60 mm Hg.

Systolic BP should be 60 to 80 mm Hg, and diastolic BP should be 40 to 50 mmHg. When the recordings are varied by 20 mm Hg in both the extremities, it implies that the neonate has a cardiac defect, such as coarctation of the aorta. If the BP of the lower extremities is 50/40 mm Hg and that of the upper extremities is 80/70 mm Hg, it indicates that the neonate has a cardiac defect, such as coarctation of the aorta. The same recordings on all the extremities signify that the neonate's heart functions properly. Variations of 10 mm Hg are still considered a normal finding in a neonate.

1 A snug, supportive bra limits milk production and reduces discomfort by supporting the tender breasts and limiting their movement. Cold packs reduce tenderness, whereas warmth increases circulation, thereby increasing discomfort. Expressing milk results in continued milk production. Plastic liners keep the nipples and areola moist, which can lead to excoriation and cracking.

The breasts of a bottle-feeding woman are engorged. The nurse should tell her to: 1 wear a snug, supportive bra. 2 allow warm water to soothe the breasts during a shower. 3 express milk from breasts occasionally to relieve discomfort. 4 place absorbent pads with plastic liners into her bra to absorb leakage.

1 The most likely cause of the infant's vomiting is insufficient attachment between infant and parent. Therefore the nurse should advise the parent to maintain skin contact with the child while feeding. To accomplish this, the nurse should teach the mother kangaroo care, which promotes attachment between the infant and the mother. Breast milk provides optimal nutrition to the baby. If the patient is able to breastfeed the baby, the nurse should encourage the patient to continue breastfeeding rather than switching to formula or cow's milk. The nurse's primary goal should be to improve the attachment between the infant and mother so that the nurse does not need to involve other family members for feeding unless absolutely necessary.

The mother of a newborn reports that the child vomits milk immediately after breastfeeding. The infant's laboratory report does not show any abnormalities. What is the most appropriate nursing intervention in this situation? 1 Teach the mother kangaroo care. 2 Ask the mother to give the child formula. 3 Ask the mother to feed the child cow's milk. 4 Teach other family members to feed the baby

4 A firm, muscular wall with less adipose tissue would ensure that the patient is able to regain the prepregnancy abdominal tone after delivery. Thus the nurse should advise the patient to do static abdominal exercises during pregnancy. The abdominal tone is not a factor based on which the nurse can determine whether the patient would have a normal vaginal delivery. Patients with weak abdominal muscles, especially those who have multifetal gestation or a large fetus, are at the risk of having diastasis recti abdominis. These abdominal striations usually do not fade away completely. Although the abdominal skin retains its tone, some striae always remain.

The nurse advises a pregnant patient to do static abdominal exercises. How would these exercises benefit the patient? 1 They will lead to a normal vaginal childbirth. 2 The patient will have diastasis recti abdominis. 3 The patient will not have any abdominal striations. 4 They will help the patient to gain proper abdominal tone after delivery.

3 Lochia rubra and a firm fundus are normal findings in a postpartum patient. Because the assessment findings do not indicate a postpartum complication, the nurse should document the findings and continue to monitor. Because the patient has a firm fundus, she does not have postpartum hemorrhage, so prostaglandins and oxytocin should not be administered. Because the fundus is firm, massage is not needed to help the fundus contract.

The nurse assesses a postpartum patient and finds that the patient has lochia rubra with a firm fundus at the level of the umbilicus. Which is the most important nursing intervention in this situation? 1 Administer prostaglandins. 2 Administer oxytocin. 3 Document the findings and continuing to monitor. 4 Massage the fundus every 15 minutes.

4 Retained placental fragments or infection cause subinvolution of the uterus. Therefore the nurse should assess the patient for any placental fragments in the uterus. Estrogen and progesterone stimulate massive growth of the uterus during pregnancy. In the postpartum stage, the hormone levels are reduced and, therefore, do not affect involution of the uterus. Platelet aggregation causes uterine muscle contraction, but it does not result in involution of the uterus.

The nurse assesses a postpartum patient several hours after delivery and suspects that the uterus is subinvoluted. What could be a potential etiology for this finding? 1 Estrogen levels 2 Progesterone levels 3 Impaired platelet aggregation 4 Retained placental fragments

1 A nulliparous woman has prominent rugae in introitus along with erythema and edema. Nulliparous women may have mild uterine cramping resulting in fewer or less severe afterpains compared to multiparous woman. Single gestation may cause mild afterpains, but it does not cause prominence of rugae or erythema or edema in the introitus. A multiparous woman usually has more afterpains compared with a nulliparous woman. Rugae are also seen in a multiparous woman, but the rugae are less prominent and flattened. Multiple gestation usually causes severe afterpains.

The nurse assessing a patient finds prominent rugae erythema and edema in the vaginal introitus. The patient reports having mild afterpains. What does the nurse interpret about the patient's clinical status from this assessment? 1 Nulliparous 2 Multiparous 3 Single gestation 4 Multiple gestation

2 A boggy or soft fundus indicates that uterine atony is present. This is confirmed by the profuse lochia and passage of clots. The first action is to massage the fundus until firm. There is no indication of a distended bladder; thus having the woman urinate will not alleviate the problem. The physician can be called after massaging the fundus, especially if the fundus does not become or remain firm with massage. Methergine can be administered after massaging the fundus, especially if the fundus does not become or remain firm with massage.

The nurse examines a woman 1 hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action is to: 1 place her on a bedpan to empty her bladder. 2 massage her fundus. 3 call the physician. 4 administer Methergine, 0.2 mg IM, which has been ordered prn.

2 A postpartum patient should be closely monitored for hemorrhage. If the perineal pad soaks in 15 minutes, the patient is hemorrhaging and needs immediate medical attention. Excessive hemorrhaging is not a normal finding after childbirth. Lochial discharge occurs after childbirth but is different from active bleeding. Hypotension may not increase bleeding in the postpartum patient.

The nurse finds that a postpartum patient's perineal pad is soaked after 15 minutes. What should the nurse infer from the finding? 1 Normal finding after childbirth 2 Sign of excessive hemorrhage 3 Presence of lochial discharge 4 Sign of postpartum hypotension

3 Couples that become new parents may develop new challenges in their personal relationship because they will spend most of their time taking care of the baby. Therefore the couple needs to make time to spend together rather than spending all of their time focused on the baby. This can be accomplished by scheduling time for one another, apart from the time dedicated to caring for the infant. The couple has to share their expectations with each other and should appreciate each other for their assistance in the child care activities.

The nurse instructs a group of nursing students about relationship issues in couples who are first-time parents. The nurse asks a student for suggestions to give new parents to prevent relationship problems. Which student response indicates the need for further teaching? 1 "Appreciate each other for the assistance." 2 "Assess your relationship on a regular basis." 3 "You should both spend more time with the baby." 4 "Share your personal expectations with each other.

4 Postpartum headaches are common and may be caused by various conditions. During delivery, an epidural or special anesthesia may be administered. Placement of the spinal needle during spinal anesthesia may cause leakage of cerebrospinal fluid into extradural space, which can lead to headaches. Nonlactating women do not necessarily have headaches; they may have reduction in milk production causing a decline in the prolactin levels, which has no effect on headaches. Gestational hypertension causes increased flow of blood and increases heart rate, but it does not aggravate headaches. Sleep deprivation is common in postpartum women, it causes mild headaches.

The nurse is assessing a postpartum patient who reports having a severe headache. What could be the reason for headache in the patient? 1 Problems with lactation 2 Inability to sleep properly 3 Maternal gestational hypertension 4 Administration of spinal anesthesia to the patient

2 If the area of saturated pad is less than 2.5 cm, it indicates that the patient had scanty bleeding. If it is less than 10 cm, then the patient had light bleeding. If the pad is saturated within 2 hours, the patient had heavy bleeding. If it is 10 cm or more, the patient had moderate bleeding.

The nurse is assessing blood loss in a postpartum patient by observing the perineal pad. The nurse finds that 1.5 cm of the pad is saturated. What patient clinical observation should the nurse infer from this finding? 1 Light bleeding 2 Scanty bleeding 3 Heavy bleeding 4 Moderate bleeding

3 To reduce breast irritation, the nurse advises the patient to wear breast shells. This will increase comfort during breastfeeding. Application of ice packs between feedings reduces breast engorgement. Hydrogel pads can be applied if the patient has sore nipples between feedings. Cold cabbage leaves applied to the breasts for 15 to 20 minutes between feedings can reduce breast engorgement by reducing tissue swelling and facilitating the flow of milk.

The nurse is caring for a 2-day postpartum patient who is breastfeeding. The patient reports breast irritation. Which intervention would be beneficial to the patient? 1 Apply ice packs to the breasts between feedings. 2 Place hydrogel pads to the breasts between feedings. 3 Tell the patient to wear breast shells. 4 Apply cold cabbage leaves to the breasts between the feedings.

3 A patient who complains of abdominal discomfort and gas pains should be encouraged to use a rocking chair because it stimulates the passage of flatus and relieves discomfort. The patient should not be encouraged to drink coffee because the caffeine present in it intensifies the pain by increasing bowel movements. Analgesic medication does not relieve gas, but the administration of antigas or antiflatulent medications may help relieve gas. Offering soups and beverages may cause more discomfort and gas in the patient.

The nurse is caring for a 24-hour-postpartum patient who had a cesarean birth with general anesthesia. The patient complains of abdominal discomfort and gas pains. What would be the most suitable nursing intervention in this situation? 1 Encourage the patient to drink coffee. 2 Administer analgesic medications to patient. 3 Encourage the patient to use a rocking chair. 4 Offer soups and beverages to the patient

1 The couple does not attempt to talk to the infant. This indicates that they lack interest in developing a bond with the infant. Calling the infant by name indicates the couple is giving importance to the individuality of the infant. In Chinese culture, the newborn is taken care of by the grandparents. This is done to promote rest and recovery in the mother after childbirth. Maintaining eye contact with the infant is a sign of attention by the parents toward the infant.

The nurse is caring for a Chinese couple who have a newborn. What patient behavior indicates that the couple lacks interest in developing an attachment with the child? The couple: 1 Never talks to the infant. 2 Always calls the infant by name. 3 Allows grandparents to take care of the child. 4 Maintains good eye contact with the infant.

3 The infant wants to interact with the mother by looking at the mother's eyes and facial expressions. Visually impaired mothers may show impassive facial expressions, which makes the infant uninterested. The infant may abandon the mother and try to interact with other family members. The mother can interact efficiently by nodding and smiling frequently while talking. This conceals the impassive facial expressions of the mother. Because the father cannot improve the facial expressions of the mother by standing nearby, the father cannot improve the interaction between the mother and infant by standing nearby. As the infant looks at the face of the mother to interact, holding the newborn's hand while talking will not improve the interaction either. The mother should give spontaneous responses to the child's actions. Waiting for others to tell her about the infant's actions may not be helpful in this situation.

The nurse is caring for a North American, postpartum patient who is visually impaired. The nurse finds that the mother is having a difficult time establishing attachment with the infant. What suggestion would the nurse give the mother in order to create an effective interaction with the infant? 1 "Ask the infant's father to stand nearby." 2 "Hold the newborn's hand while talking." 3 "Nod and smile while talking to the infant." 4 "Get informed of the actions of the infant."

4 To facilitate father-infant bonding, the nurse should include the father while giving instructions about newborn care. If the nurse asks the father to change the baby's diaper, the father may be anxious and may not be willing to do it. Instead, the nurse should show the father how to change the diapers and then ask the latter to return demonstrate the process. Asking the father why he is anxious or reassuring him that it will take time to get used to the newborn may not improve father-child bonding or reduce his fear about handling the newborn

The nurse is caring for a family who has a newborn. The father appears to be very anxious and nervous when the newborn's mother asks him to bring the baby. Which nursing intervention is most beneficial in promoting father-infant bonding? 1 Hand the father the newborn and instruct him to change the diaper. 2 Ask the father why he is so anxious and nervous. 3 Tell the father that he will get used to the newborn in time. 4 Provide education about newborn care when the father is present.

1, 2, 4 Engorgement in a breastfeeding woman requires careful management to preserve the milk supply while managing the increased blood flow to the breasts. Taking warm showers can increase milk flow. Frequent feedings will permit the breasts to empty fully and establish the supply-demand cycle that is appropriate for the infant. Cold cabbage leaves work well to reduce pain and swelling and should be applied every 4 hours. Binding the breasts is not appropriate because it decreases the milk supply. To ease the discomfort associated with sore nipples, the mother may apply topical preparations such as purified lanolin or hydrogel pads.

The nurse is caring for a lactating patient with a body temperature of 102° F (38.9° C). The nurse finds that the patient's breasts are engorged, swollen, hard, and red. Which interventions related to patient care would be helpful in managing breast engorgement? Select all that apply. 1 Taking warm showers before breastfeeding 2 Nursing the baby frequently 3 Using a tight supportive bra or a breast binder 4 Applying cold cabbage leaves to the breasts 5 Avoiding use of lanolin or hydrogel pads

4 Swollen and tender breasts are caused by distention in the breast. Breast distention is caused by the congestion of veins and lymphatics in the breast, making them tender and warm to the touch. A decline in the prolactin levels occurs when a patient does not breastfeed, resulting in the lapse of milk production. The accumulation of milk does not aggravate the tenderness of the breasts; instead, it makes them fuller in appearance. Engorgement of the breast occurs while feeding, and it reduces with frequent feeding and proper care.

The nurse is caring for a nonbreastfeeding postpartum patient. The patient reports having swollen and tender breasts. What does the nurse anticipate as the reason for these symptoms? 1 Decline in the prolactin levels 2 Accumulation of milk in the breast 3 Engorgement of the breast tissues 4 Congestion of veins in the breast

1 Native American patients do not initiate breastfeeding until their breast milk comes in. They avoid feeding the first milk (colostrum) to the child. In this situation, the nurse should inform the patient about the health benefits of feeding colostrum to the child. Mother's milk is the best source of nutrition for the baby; the formula milk is not as nutritious. The mother is also unlikely to have problems ejecting milk. Native American mothers tend to avoid feeding the baby unless the colostrum stops ejecting and the mother starts ejecting milk. Because the patient has not yet started breastfeeding, it is unlikely that the patient has sore nipples, so the nurse would not need to apply antiinflammatory ointment.

The nurse is caring for a postpartum Native American patient who is unwilling to breastfeed the baby until after the breast milk has come in. What will the nurse do in this situation? 1 Explain the importance of first milk to the patient. 2 Ask the patient to give formula milk to the infant. 3 Use additional measures for milk ejection in the patient. 4 Apply antiinflammatory ointment around the patient's nipples.

2 Lochia serosa is a pink or brown fluid containing old blood, serum, leukocytes, and tissue debris. The lochia serosa starts 3 to 4 days after childbirth. Lochia alba is a yellow to white fluid containing leukocytes, serum, epithelial cells, bacteria, and decidua. It starts 10 days after childbirth in most women. In the case of a vaginal tear, the patient would have bright red bleeding for more than 2 hours after delivery. Lochia rubra, a bright red fluid containing small clots, starts from the end of the childbirth and disappears within 2 hours.

The nurse is caring for a postpartum patient and finds that the patient has brown vaginal discharge. What is the cause of the discharge? 1 Lochia alba 2 Lochia serosa 3 Lochia rubra 4 Vaginal or cervical tear

4 The psychosocial assessment includes evaluating adaptation to parenthood, as evidenced by the parents' reactions to the baby and interactions with the new baby. Good attachment behaviors include seeking eye contact with the baby and talking to the baby during caretaking activities; the nurse should investigate the behaviors when these are not observed. Changing diapers, positioning baby comfortably, and maintaining eye-to-eye contact are appropriate behaviors that increase parent-infant attachment.

The nurse is caring for a postpartum patient who gave birth recently. The nurse is evaluating the parent's behavior toward the new baby. Which parent-infant behaviors should the nurse investigate further? 1 Change the baby's diapers when needed. 2 Position the baby comfortably. 3 Demonstrate eye-to-eye contact with the baby. 4 Complete the child care activities silently, without looking at the baby.

3 Vaginal deliveries cause the pelvic muscles and ligaments to stretch and weaken. Kegel exercises help strengthen the pelvic floor muscles and thereby can prevent uterine complications, such as prolapse. The physical activity of climbing stairs may delay the process of healing from an episiotomy, so it is usually avoided. However, avoiding stairs does not prevent uterine prolapse. A diet high in protein is necessary to build muscle strength, but it cannot prevent uterine prolapse. Because the patient has already undergone delivery, sleeping in prone position does not cause any harm.

The nurse is caring for a postpartum patient who had a normal vaginal delivery. The nurse tells the patient, "This will help you prevent uterine prolapse in later stages of life." Which instruction from the primary health care provider (PHP) is the nurse most likely explaining to the patient? 1 "Avoid climbing of the stairs." 2 "Maintain a high-protein diet." 3 "Do Kegel exercises every day." 4 "Avoid sleeping in the prone position."

3 Patients with episiotomy may have soreness and back pain. To relieve soreness and back pain, the nurse should advise the patient to place an ice pack on the affected area. This provides comfort and reduces the inflammation and pain. A sitz bath helps relieve lower back pain and discomfort, so the patient should be encouraged to use sitz baths at a temperature of 38° to 40° C (100° to 104° F) at least twice a day to prevent edema. Not cleaning the perineal area may cause infection, so the nurse should advise the patient to clean her perineum frequently. Drinking plenty of water and eating foods such as fresh fruit and vegetables that contain fibers can relieve constipation or hemorrhoids but does not help reduce soreness.

The nurse is caring for a postpartum patient who has an episiotomy wound. The nurse finds that the patient has soreness at the incision site and lower back pain. What does the nurse tell the patient? 1 Avoid using sitz baths. 2 Avoid cleaning the perineal area frequently. 3 Place a covered ice pack on the affected area. 4 Drink plenty of water and eat foods containing fiber

4 Orthostatic hypotension develops as a result of splanchnic engorgement after birth, which causes dizziness immediately upon standing upright. Decreased blood pressure results from hypovolemia due to hemorrhage. Manifestations of endometritis include pain, fever, and abdominal tenderness, along with continued flow of lochia serosa or alba up to 3 to 4 weeks. Manifestations of hemorrhoids include itching, discomfort, and bright red bleeding upon defecation. Puerperal sepsis manifests by an increase in the maternal temperature up to 38° C (100.4° F) 24 hours after childbirth. This increased temperature persists or recurs for about 2 days.

The nurse is caring for a postpartum patient who reports dizziness upon standing. What does the nurse believe to be the most likely cause for this occurrence? 1 Endometritis 2 Hemorrhoids 3 Puerperal sepsis 4 Orthostatic hypotension

4 While interacting with the parents of an infant who are hearing-impaired, the nurse should suggest that the parents show video recordings to the infant to improve vocalization, as this helps the newborn become familiar with human voices. Interacting with the child using sign language can enhance communication, but may not help to improve vocalization. Playing rhymes and music at a very high volume may damage the eardrum of the infant and can lead to hearing impairment. Asking a family member or friend to talk to the baby is a good solution, but it may not be a practical solution if the parents care for the child independently.

The nurse is caring for a postpartum patient with a hearing impairment. The nurse finds that the patient's partner is also hearing-impaired. What does the nurse suggest to both parents to improve vocalization in the newborn? 1 Interact with the infant using sign language. 2 Play rhymes and music at a very high volume. 3 Ask a family member or friend to talk to the baby. 4 Show the infant recordings of television programs.

3 Estrogen and progesterone play a vital role in the development of the uterus during pregnancy. They are responsible for the growth of the uterus and may cause hypertrophy and hyperplasia of the uterine muscle cells. A decrease in estrogen and progesterone results in decreased growth of the uterus, which might even lead to miscarriage. Low estrogen and progesterone may not cause increased UCs. Moreover, the pituitary hormone oxytocin is primarily responsible for UCs during labor. Low levels of estrogen and progesterone lead to abnormally low growth of the uterus. Estrogen and progesterone also increase the blood circulation in the mother. Low levels of these hormones would decrease blood circulation.

The nurse is caring for a pregnant woman who has low levels of estrogen and progesterone. What does the nurse expect may occur as a result of the low hormone levels? 1 Massive growth of the uterus during pregnancy 2 Increased uterine contractions (UCs) during labor 3 Decreased growth of the uterus during pregnancy 4 Increased blood circulation to the uterus during pregnancy

4 Kegel exercises strengthen and increase the elasticity of the pubococcygeus muscle, which is the main perineal muscle. They improve vaginal tone and also help prevent stress incontinence and hemorrhoids. Kegel exercises do not prevent urine retention, relieve lower back pain, or tone abdominal muscles.

The nurse is helping prepare a patient for discharge after childbirth. During a teaching session, the nurse instructs the patient to do Kegel exercises. What is the purpose of these exercises? 1 To prevent urine retention 2 To provide relief of lower back pain 3 To tone the abdominal muscles 4 To strengthen the perineal muscles

2 During the postpartum period, maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. A rising pulse is an early sign of excessive blood loss because the heart pumps faster to increase the supply of blood. A body temperature of 100.4º F is a normal finding. A respiratory rate of 22 breaths/min indicates that the patient has no internal bleeding. A blood pressure of 120/80 mm Hg does not indicate that the patient has hemorrhage.

The nurse is monitoring a postpartum patient for signs of hemorrhage. Which observation would indicate excessive blood loss? 1 A body temperature of 100.4º F 2 An increase in pulse from 88 to 102 beats/min 3 An increase in respiratory rate from 18 to 22 breaths/min 4 A blood pressure change from 130/88 to 120/80 mm Hg

3 Rubella vaccine is made from duck eggs; therefore women who are allergic to duck eggs can develop a hypersensitivity reaction to the vaccine. As a result, the patient might develop rashes on her skin. The PHP would prescribe adrenaline to combat hypersensitivity reactions. Oxytocin is injected to increase the tone of the uterine muscles but not to combat hypersensitivity. Rh immune globulin suppresses the immune system, which would worsen the condition; therefore this medication is unlikely to be prescribed. Magnesium sulfate is used for preeclampsia and is not used to minimize hypersensitivity reactions caused by rubella vaccine.

The nurse is preparing to administer rubella vaccine to a patient during the postpartum period. At the follow-up visit, the patient reports to the nurse that she has rashes on her skin. What does the nurse expect the primary health care provider (PHP) to prescribe in this situation? 1 Oxytocin (Pitocin) 2 Rh immune globulin 3 Adrenaline (Epinephrine) 4 Magnesium sulfate

4 The patient must not become pregnant for 3 months after the rubella vaccination because of its potential teratogenic effects. The rubella vaccine is made from duck eggs, so an allergic reaction may occur in the patients with egg allergies. Because the virus is not transmitted through breast milk, the patient may continue to breastfeed even after vaccination. Transient arthralgia (joint pain) and skin rashes are the common adverse effects of the rubella vaccine.

The nurse is preparing to administer rubella vaccine to a postpartum patient. What should the nurse tell the patient? 1 "The vaccine is safe even if you have an egg allergy." 2 "You cannot breastfeed for 5 days after taking the vaccine." 3 "You will not have joint pains or skin rashes after the vaccination." 4 "You should use proper contraception for 3 months after the vaccination."

2 In most cases, the patient can continue to breastfeed. If the affected breast is too sore, the patient can pump the breast gently. Regular emptying of the breast is important to prevent the formation of abscess. Use of a supportive bra suppresses milk production and prevents breast engorgement. Additional supportive measures include ice packs, breast supports, and analgesics. Antibiotic therapy assists in resolving the mastitis within 24 to 48 hours.

The nurse is providing instructions to a postpartum patient who has been diagnosed with mastitis. Which statement made by the patient indicates a need for further teaching? 1 "I need to wear a supportive bra to relieve the discomfort." 2 "I need to stop breastfeeding until this condition resolves." 3 "I can use analgesics to alleviate some of the discomfort." 4 "I need to take antibiotics, and I should begin to feel better in 24 to 48 hours."

2 The woman should be encouraged to hold her infant in the en face position and make eye contact with him. Talking and cooing to her son is a normal infant-parent interaction. Cuddling is a normal infant-parent interaction. Sharing her son's success at feeding is a normal infant-parent interaction.

The nurse observes several interactions between a postpartum woman and her new son. What behavior (if exhibited by this woman) does the nurse identify as a possible maladaptive behavior regarding parent-infant attachment? 1 Talks and coos to her son 2 Seldom makes eye contact with her son 3 Cuddles her son close to her 4 Tells visitors how well her son is feeding

1 Mexican mothers may believe that excessive admiration may result in evil eye (mal de ojo). They feel that children are more susceptible to evil eye. This behavior does not indicate that the mother does not have a good attachment with the baby. Similarly, this evasive behavior does not indicate the mother is worried about infection or the baby becoming fussy after exposure to new faces.

The nurse observes that a Spanish-speaking patient of Mexican descent does not like the nurses to lean in and admire her newborn. What is the most likely reason for this behavior? The mother: 1 Wants to protect the infant from evil eye. 2 Does not have good attachment with the baby. 3 Feels that the baby may acquire infection. 4 Feels that the baby may become fussy seeing new faces.

1 Patients of Southeast Asian descent believe that minimal touching and cuddling of the newborn after birth protects the child from evil spirits. If the patient had postpartum blues, the patient may show different symptoms such as crying episodically. If the patient does not hold or feed the child, it would indicate that the patient is afraid of handling the child. Avoiding cuddling and touching the newborn does not indicate that the patient is improving the baby's strength and immunity. Southeast Asians believe that massaging the newborn would be helpful in improving the baby's strength and immunity.

The nurse observes that a patient of Southeast Asian descent avoids cuddling and touching her newborn. What can the nurse infer about the patient from these observations? The patient: 1 May be trying to protect the child from evil spirits. 2 Is depressed because of postpartum blues. 3 Is afraid of handling the child all by herself. 4 Is improving the baby's strength and immunity

1 When parents speak, infants tend to get excited and dance in tune with the parent's voice. This indicates that the infant is responding well to the patient. The newborn should ideally look at the parent when the parent tries to communicate. If the newborn looks toward the wall, it indicates that the newborn is not responding well to the parent. If the newborn keeps the upper and lower limbs still when the parent interacts, it indicates that the newborn is not responding well to the patient.

The nurse observes that the newborn is responding well to the parent. Which behavior from the newborn did the nurse observe to come to this conclusion? The newborn: 1 Was dancing in tune with the parent's voice. 2 Looked at the wall upon hearing the parent's voice. 3 Was not kicking its legs in tune to the parent's voice. 4 Was not waving its arms in tune to the parent's voice.

A patient with a history of gonorrheal infection has just delivered a baby. What immediate intervention should the nurse provide to the newborn to ensure safety? 1 Place the newborn in incubator. 2 Administer ophthalmic solution. 3 Perform a heelstick puncture test. 4 Provide ventilator support to the newborn.

The nurse should administer erythromycin ophthalmic solution to the newborn within 2 hours of birth to prevent ophthalmia neonatorum caused by gonorrheal infection. Incubation is preferred when a neonate has hypothermia in order to regulate the body temperature. Heelstick puncture is performed to detect abnormalities in blood levels only if the neonate has any infection. Ventilator support is provided if the neonate's heart rate is below 100 beats/min. However, the heart rate is not decreased due to gonorrheal infection.

1 If 15 mL of fetal blood is detected in the maternal circulation of an Rh-negative woman, as indicated by Kleihauer-Betke test, then 300 mcg (1 vial) of Rh immune globulin is usually sufficient to prevent maternal sensitization. A dose of 400 mcg of intramuscular Rh immune globulin may result in an overdosage. A dose of 100 mcg or 200 mcg of intramuscular Rh immune globulin is not sufficient to prevent maternal sensitization.

The nurse tells the primary health care provider (PHP) that there is 15 mL of fetal blood in maternal circulation, as detected by Kleihauer-Betke test, in an Rh-negative patient. What does the nurse expect the PHP to prescribe to this patient? 1 300 mcg of intramuscular Rh immune globulin 2 400 mcg of intramuscular Rh immune globulin 3 100 mcg of intramuscular Rh immune globulin 4 200 mcg of intramuscular Rh immune globulin

2 The intensity of afterpains depends on the lactating status of the patient, the number of times a patient has been pregnant, and the type of gestation whether single or multiple. Breastfeeding stimulates uterine contractions (UCs), which increase afterpains. First-time mothers may have only mild uterine cramping, so nulliparous women may have mild afterpains compared with the multiparous women. An overdistended uterus caused by multiple gestation and polyhydramnios makes the afterpains more noticeable. Therefore a patient who is lactating, is multiparous, and had multiple gestation would have more afterpains. If a patient is lactating but is nulliparous and had single gestation, the intensity of afterpains would be less. A patient who is nonlactating, is nulliparous, and has oligohydramnios may have less afterpains. The patient who had multiple gestation but is nonlactating and nulliparous may have less intense afterpains.

The postpartum patient reports to the nurse, "I am having intolerable pain after the delivery." Which conditions would cause the patient's afterpains? 1 Lactating, nulliparous, single gestation 2 Lactating, multiparous, multiple gestation 3 Nonlactating, nulliparous, oligohydramnios 4 Nonlactating, nulliparous, multiple gestation

4, 5 After receiving the first dose of Varivax, the patient must take the second dose 4 to 8 weeks later. The patient must use contraception for 1 month after being vaccinated to avoid pregnancy because the vaccine has teratogenic effects. Mothers who receive the varicella vaccine can continue to breastfeed because the vaccine is not transmitted to the fetus through breast milk. Postpartum women usually have low immunity, so one dose is not sufficient. Stopping of all medications is not necessary and can endanger the patient.

The primary health care provider (PHP) has asked the nurse to administer varicella vaccine (Varivax) to a postpartum patient on the day of discharge from the hospital. What instruction does the nurse give the patient before administering the vaccine? Select all that apply. 1 "Stop breastfeeding after receiving the vaccine." 2 "You need not return to the hospital because one dose is enough for you." 3 "Stop taking all medications after returning home." 4 "You must return for a second dose in 4 to 8 weeks." 5 "Use contraception for 1 month to avoid pregnancy."

2 Oxytocin (Pitocin) is administered immediately after birth to retain a firm and well-contracted uterus. A patient with vaginal delivery may need oxytocin (Pitocin) because the uterine muscles are stretched to a larger extent. Therefore oxytocin (Pitocin) is administered to induce contraction. Thyroiditis, or the inflammation of the thyroid gland, causes anemia and postpartum hemorrhage, but it does not affect elasticity of the uterus. A patient who had a cesarean delivery may not need oxytocin (Pitocin), because the uterus is not as stretched compared with that of a patient who had a vaginal delivery. Gestational diabetes does not decrease oxytocin levels, so the patient may not need an oxytocin supplement.

The primary health care provider (PHP) instructed the nurse to administer oxytocin (Pitocin) to the patient immediately after birth. What could be the patient's clinical status for the PHP's instruction? 1 Thyroiditis 2 Postvaginal delivery 3 Delivery by cesarean section 4 Gestational diabetes

4 Puerperal sepsis is a condition in which a woman's genital tract becomes infected due to low immunity caused by long labor, severe bleeding, or dehydration. Therefore the nurse should assess the patient for puerperal sepsis if the temperature of the woman after childbirth is raised to 100.4° F. Blood pressure is routinely assessed in postpartum patients to detect hemorrhage. A rapid pulse rate indicates the presence of hypovolemia as a result of hemorrhage. The respiratory rate is measured because hypoventilation can occur after a high subarachnoid block or epidural narcotic following a cesarean birth.

Twenty-four hours after childbirth, a patient developed a high temperature of 100.4° F. Which monitoring action is most important for the nurse? 1 Pulse rate 2 Blood pressure 3 Respiratory rate 4 Assess for puerperal sepsis

Newborns are at high risk for injury if appropriate safety precautions are not implemented. Parents should be taught to:

Use a rear-facing carseat

3 In postpartum women, the colostrum transforms to mature milk within approximately 72 to 96 hours after birth. This mature milk is slightly bluish in color. Thus, based on the finding, the nurse would infer that the patient is expressing mature milk. There are no secretions from the nipples in cases of breast abscess. Colostrum is clear, yellow fluid, which is commonly secreted immediately after birth. Fibrocystic changes in the breast are characterized by nodular lumps in the breast, which are always palpable in the same location.

What does the nurse infer about the patient's condition from the finding of slightly bluish-colored milk expressed from the breasts of a postnatal patient? 1 The patient may have a breast abscess. 2 The patient may be expressing colostrum. 3 The patient may be expressing mature milk. 4 The patient may have fibrocystic changes in the breast.

4 Suppression of lactation is recommended in cases of neonatal death. To suppress lactation, the nurse should advise the patient to wear a breast binder continuously for the first 72 hours after delivery. Running warm water over the breast stimulates lactation. Mild analgesics can be administered to reduce breast engorgement, but they are not used to suppress lactation. Administration of oral or intravenous fluids may stimulate lactation.

What intervention does the nurse perform to suppress lactation in a patient who had a stillbirth? 1 Run warm water over the patient's breasts. 2 Administer strong analgesics. 3 Administer oral and intravenous fluids. 4 Advise the patient to wear a breast binder for the first 72 hours after giving birth.

2 Most women experience a heavier than normal flow during the first menstrual cycle, which occurs by 3 months after childbirth. She can expect her first menstrual cycle to be heavier than normal, and the volume of her subsequent cycles to return to prepregnant levels within three or four cycles.

What statement by a woman who just gave birth indicates that she knows what to expect about her menstrual activity after childbirth? 1 "My first menstrual cycle will be lighter than normal and then will get heavier every month thereafter." 2 "My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles." 3 "I will not have a menstrual cycle for 6 months after childbirth." 4 "My first menstrual cycle will be heavier than normal and then will be light for several months after."

4 The levels of steroid hormones such as progesterone and estrogen suddenly drop after childbirth. This leads to reduced renal function, which persists for 1 month after delivery. This leads to decreased urine output in the patient. Lactation may result in lactosuria. The patient exhibits signs such as fever and pain during urination if the patient has a urinary tract infection. Pregnancy-induced hypotonia results in decreased tone of the muscles supporting the pelvic structures. This poor muscular tone is detected during pregnancy and requires about 6 weeks to revert to the nonpregnant state.

What would the nurse assume is the cause of reduced urine output in a postpartum patient on the second day after delivery with no other abnormal signs or symptoms? 1 Lactation 2 Urinary tract infection 3 Pregnancy-induced hypotonia 4 Low levels of progesterone and estrogen

2, 3, 5 Suggestions for coping with postpartum blues include: (1) Remember that the "blues" are normal and that both the mother and the father or partner may experience them. (2) Get plenty of rest; nap when the baby does if possible. Go to bed early, and let friends and family know when to visit and how they can help. (Remember, you are not "Supermom.") (3) Use relaxation techniques learned in childbirth classes (or ask the nurse to teach you and your partner some techniques). (4) Do something for yourself. Take advantage of the time your partner or family members care for the baby—soak in the tub (a 20-minute soak can be the equivalent of a 2-hour nap), or go for a walk. (5) Plan a day out of the house—go to the mall with the baby, being sure to take a stroller or carriage, or go out to eat with friends without the baby. Many communities have churches or other agencies that provide child care programs such as Mothers' Morning Out. (6) Talk to your partner about the way you feel—for example, about feeling tied down, how the birth met your expectations, and things that will help you (do not be afraid to ask for specifics). (7) If you are breastfeeding, give yourself and your baby time to learn. (8) Seek out and use community resources such as La Leche League or community mental health centers.

When helping a woman cope with postpartum blues, what suggestions should the nurse offer? Select all that apply. 1 Have the father take over care of the baby, because postpartum blues are exclusively a female problem. 2 Get plenty of rest. 3 Plan to get out of the house occasionally. 4 Do not ask for help because this will not foster independence. 5 Use La Leche League or community mental health centers.

3 Vacillating between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn is characteristic of the taking-in stage, which lasts for the first few days after birth. Expressing a strong need to review events and her behavior during the process of labor and birth is characteristic of the taking-in stage, which lasts for the first few days after birth. One week after birth, the woman should exhibit behaviors characteristic of the taking-hold stage. This stage lasts for as long as 4 to 5 weeks after birth. Reestablishing her role as a spouse/partner reflects the letting-go stage, which indicates that psychosocial recovery is complete. Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect.

When making a visit to the home of a postpartum woman 1 week after birth, the nurse should recognize that characteristically the woman would: 1 express a strong need to review events and her behavior during the process of labor and birth. 2 exhibit a reduced attention span, limiting readiness to learn. 3 vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn. 4 have reestablished her role as a spouse/partner.

3 The findings indicate a full bladder, which pushes the uterus up and to the right or left of midline. The recommended action is to empty the bladder. If the bladder remains distended, uterine atony could occur, resulting in a profuse flow. A firm fundus should not be massaged because massage could overstimulate the fundus and cause it to relax. Methergine is not indicated in this case because it is an oxytocic and the fundus is already firm. This is not an expected finding, and emptying the bladder is required. STUDY TIP: You have a great resource in your classmates. We all have different learning styles, strengths, and perspectives on the material. Participating in a study group can be a valuable addition to your nursing school experience.

When palpating the fundus of a woman 18 hours after birth, the nurse notes that it is firm, 2 fingerbreadths above the umbilicus, and deviated to the left of midline. The nurse should: 1 massage the fundus. 2 administer Methergine, 0.2 mg PO, that has been ordered prn. 3 assist the woman to empty her bladder. 4 recognize this as an expected finding during the first 24 hours following birth.

1, 2, 3, 4 The skepticism, open or hidden, of health care professionals presents an additional and unneeded hurdle for the parents. After the parents' capabilities have been assessed (including some the nurse may not have expected), the nurse can help find ways to assist the parents that focus on their strengths. The Internet affords an extra teaching tool for the deaf, as do videos with subtitles or nurses signing. A number of electronic devices can turn sound into light flashes to help pick up a child's cry. Sign language is acquired readily by young children. Childbirth education and other materials are available in Braille. Other sensory output can be provided by the parent, other people can participate, and other coping devices can be used.

When working with parents who have some form of sensory impairment, what information should nurses consider when writing a plan of care? Select all that apply. 1 One of the major difficulties visually impaired parents experience is the skepticism of health care professionals. 2 The best approach for the nurse is to assess the parents' capabilities rather than focusing on their disabilities. 3 Technologic advances, including the Internet, can provide deaf parents with a full range of parenting activities and information 4 Childbirth education and other materials are available in Braille.

2, 3 Jordanian mothers have a 40-day lying-in after birth, during which their mothers or sisters care for the baby. Japanese mothers rest for the first 2 months after childbirth. Asian mothers must remain at home with the baby up to 30 days after birth and are not supposed to engage in household chores, including care of the baby. Hispanic practice involves many food restrictions after childbirth, such as avoiding fish, pork, and citrus foods. Vietnamese mothers may give minimal care to their babies and refuse to cuddle or further interact with the baby to ward off "evil" spirits.

Which culturally appropriate beliefs should the maternity nurse use to incorporate parental-infant attachment into the plan of care? Select all that apply. 1 Asian mothers are encouraged to return to work as soon as possible. 2 Jordanian mothers have a 40-day lying-in after birth. 3 Japanese mothers rest for the first 2 months after childbirth. 4 Encourage Hispanics to eat plenty of fish and pork to increase vitamin intake. 5 Encourage Vietnamese mothers to cuddle with the newborn.

3 The fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it to relax. Administration of Methergine can help prevent postpartum hemorrhage. Voiding frequently can help the uterus contract, thus preventing postpartum hemorrhage. Rest and nutrition are helpful for enhancing healing and preventing hemorrhage. Test-Taking Tip: Stay away from other nervous students before the test. Stop reviewing at least 30 minutes before the test. Take a walk, go to the library and read a magazine, listen to music, or do something else that is relaxing. Go to the test room a few minutes before class time so that you are not rushed in settling down in your seat. Tune out what others are saying. Crowd tension is contagious, so stay away from it.

Which measure is least effective in preventing postpartum hemorrhage? 1 Administering Methergine, 0.2 mg every 6 hours for four doses, as ordered 2 Encouraging the woman to void every 2 hours 3 Massaging the fundus every hour for the first 24 hours following birth 4 Teaching the woman the importance of rest and nutrition to enhance healing

A, B, C Pelvic muscles support the pelvic organs such as the uterus, rectum, and bladder. Relaxation or weakness of this pelvic muscular support may lead to prolapse of these organs in the future. The small intestine is not a pelvic organ. Inguinal vessels are not held in place by pelvic muscular support.

Which structures may be affected due to the relaxation of pelvic muscular support that occurs after childbirth? Select all that apply. A Uterus B Rectum C Bladder D Small intestine E Inguinal vessels

1 Applying a covered ice pack to the perineum from front to back during first 24 hours decreases edema and increases comfort. Using two or more perineal pads would be helpful in absorbing the heavy menstrual flow but will not reduce the pain or promote perineal healing. Sitz baths and Kegel exercises are important measures to provide pain relief and comfort to the patient with a fourth-degree laceration. Therefore the nurse should not advise the patient to avoid taking sitz baths and performing perineal (Kegel) exercises.

While assessing a postpartum patient, the nurse finds that the patient has a fourth-degree laceration. What immediate interventions should the nurse perform while caring for the patient? 1 Apply an ice pack to limit edema during the first 12 to 24 hours. 2 Instruct the patient to use two or more perineal pads. 3 Teach the patient to avoid taking sitz baths. 4 Remind the patient to avoid doing perineal (Kegel) exercises.

4 According to traditional Hispanic customs, fathers do not see their wives or infants until they are cleaned and dressed. It is believed that this custom incorporates the individuals into the family and integrates the family. It does not imply that the father is too scared to hold the baby. In this situation, the father is following the traditional Hispanic custom by not seeing the baby after birth. It does not implicate that the father has no time to see the baby. The father would want to see the baby as soon as it is cleaned and dressed.

While caring for a Hispanic patient, the nurse asks the infant's father to hold the baby after its birth. The father is unwilling to see the baby. What reason would the nurse attribute to this unwillingness? The father: 1 Is too scared to hold the baby. 2 Has no time to visit the baby. 3 Is not following the traditional Hispanic custom. 4 Is doing it to integrate the individuals into the family

4 While no family follows just one pattern, in American culture the paternal grandparents are typically considered secondary to the maternal grandparents after the baby is born. This is because a woman may be closer to her own parents and feel more comfortable accepting their help than that of her partner's family. As a result, paternal grandparents may be naturally less involved with the newborn. There are no cultural rules in the American culture dictating that paternal grandparents care for the second-born child or bond with the baby only after 6 months. Grandparents are not typically responsible for the financial expenses of the baby in the United States.

While caring for a patient, the nurse notices that the newborn's paternal grandparents visit the newborn and leave after an hour. The maternal grandparents, on the other hand, stay all day with the couple to look after the newborn. What could be the reason for this in terms of traditional paternal grandparents' cultural behaviors? 1 They care for the second born child. 2 Typically, they are called to care for baby after 6 months. 3 They feel that they are responsible only for the financial expenses of the child. 4 They do not feel responsible for the care of the newborn or new mother.

1 Estrogen causes fluid accumulation and after childbirth a woman's estrogen levels decrease, leading to postpartal diuresis. Postpartal diuresis results in profuse sweating and an increase in urinary output. The hormone prolactin plays a role in milk production, but not in fluid retention so a decrease in prolactin does not cause fluid loss, diuresis, and sweating. Progesterone helps in the formation of the uterine endometrium and prevents uterine contractions. An increase in progesterone levels may cause uterine atony, but not postpartal diuresis that manifests as increased urinary output and profuse sweating. Human chorionic gonadotropin (hCG) levels decrease rapidly after delivery, but this does not cause diaphoresis. Therefore, an increase in hCG levels would not cause sweating or increased urinary output in this client.

While caring for a postpartum patient, the nurse determines that the client has increased urinary output and profuse nighttime sweating. What could cause these symptoms? 1 Decreased estrogen levels 2 Decreased prolactin levels 3 Increased progesterone levels 4 Increased human chorionic gonadotropin level

2 Children may feel insecure when parents pay more attention to a newborn sibling. The older child may develop feelings of sibling rivalry and exhibit negative behaviors, such as increased attention seeking and aggression toward the baby. Therefore trying to grab the attention of the parents indicates that the child has not adapted well to the newborn. Positive behaviors, such as increased interest and concern for the baby, indicate effective adaptation. Therefore expressing a desire to stay with the mother and newborn in hospital, watching the baby silently, and being willing to feed the baby does not indicate a lack of adaptation.

While caring for a postpartum patient, the nurse observes that the patient's older child is not adapting well to the newborn and may have feelings of sibling rivalry. What behavior of the older child would make the nurse conclude this? 1 Watches the baby silently in the hospital 2 Always tries to grab the parents' attention 3 Always wants to be with the mother and newborn 4 Asks to feed the newborn with a milk bottle

3 Algerian mothers tightly wrap the infant in swaddling clothes to protect them physically and physiologically, a custom followed by Algerians as a part of the acquaintance process. Algerians follow this custom to give physical and psychological protection but not to protect the infant from evil spirits. Vietnamese mothers interact minimally with the infants to protect them from evil spirits. The mother has to accept the assistance from others, as she alone cannot take care of the baby. Therefore she cannot avoid others touching the infant. Asian and Jordanian mothers hand over the baby to the grandparents immediately after birth. They do this to get some rest after childbirth.

While caring for an Algerian patient, the nurse suggests that the patient give kangaroo care to the infant. The mother is unwilling to follow the suggestion of the nurse. What is the reason for this unwillingness? The patient is attempting to: 1 Protect the infant from evil spirits. 2 Prevent others from touching the baby. 3 Protect the infant physically and psychologically. 4 Take adequate rest after the birth of the child.

1 The fundus descends gradually from the time of childbirth and returns to its normal nonpregnant state. By the sixth day after childbirth, it can be located halfway between the umbilicus and the symphysis pubis. The fundus rises to approximately 1 cm above the umbilicus within 12 hours of childbirth. Within 24 hours, the fundus descends 1 to 2 cm, and the size of the uterus is the same as during 20 weeks' gestation. By the sixth week, the uterus returns to its normal, nonpregnant state.

While examining the postpartum patient, the nurse finds that her fundus is located halfway between the umbilicus and the symphysis pubis. When would the nurse suspect was about the time of the patient's delivery? 1 6 days ago 2 12 hours ago 3 24 hours ago 4 6 weeks ago

2 Postpartum women spend most of their time caring for the infant, especially those mothers who breastfeed and may not easily be able to share child care duties with their partners. As a result, the infant's father may feel depressed, bored, and jealous of the infant. The infant's father should express these feelings so that the mother can make more time for her partner. It is not appropriate to tell the father to spend more time with his friends, as this does not solve the problem in the home. Even if the father comes home early from work, the mother may not be able to spend time with the father, so this suggestion is not necessarily helpful. Engaging in other activities may relieve the infant's father from boredom but not from depression and jealousy. The father would get relieved of these feelings by having the mother's attention and care.

While speaking to the newborn's father in a well child visit, the nurse finds out that the newborn's father is feeling depressed and bored, as the mother spends most of her time with the infant. What instruction should the nurse give to the father in this situation? 1 "Spend more time with your friends." 2 "Share your feelings with your partner." 3 "Work fewer hours and come home early." 4 "Try to distract yourself with other activities."

3 Patting or gently rubbing the infant's back provides comfort to the infant after feeding. Gentle stroking on the infant's back helps to soothe and quiet the infant. Making eye contact with the infant helps to develop a bond and enhances the trust between the mother and infant. Touching the infant with the mother's fingertips and caressing the infant's trunk help to develop attachment with the infant.

While teaching the patient about breastfeeding, the nurse instructs the patient to rub the infant's back after feeding. What is the reason for this instruction? 1 To develop trust in the infant 2 To quiet and soothe the infant 3 To provide comfort to the infant 4 To promote attachment with the infant

3 Afterbirth pains are more common in multiparous women because first-time mothers have better uterine tone. A large infant or multiple infants overdistend the uterus. The cramping that causes afterbirth pains arises from periodic, vigorous contractions and relaxations that persist through the first part of the postpartum period. Breastfeeding intensifies afterbirth pain because it stimulates contractions.

With regard to afterbirth pains, nurses should be aware that these pains are: 1 caused by mild, continual contractions for the duration of the postpartum period. 2 more common in first-time mothers. 3 more noticeable in births in which the uterus was overdistended. 4 alleviated somewhat when the mother breastfeeds.

3 Excess fluid loss can occur through perspiration and urinary output as well as through other means. Kidney function usually returns to normal in about a month. Diastasis recti abdominis is the separation of muscles in the abdominal wall; it has no effect on the voiding reflex. Bladder tone usually is restored 5 to 7 days after childbirth. STUDY TIP: Begin studying by setting goals. Make sure they are realistic. A goal of scoring 100% on all exams is not realistic, but scoring an 85% may be a better goal.

With regard to the condition and reconditioning of the urinary system after childbirth, nurses should be aware that: 1 kidney function returns to normal a few days after birth. 2 diastasis recti abdominis is a common condition that alters the voiding reflex. 3 fluid loss through perspiration and increased urinary output account for a weight loss of more than 2 kg during the puerperium. 4 with adequate emptying of the bladder, bladder tone usually is restored 2 to 3 weeks after childbirth.