OB Ch 27 Care of the Mother and Newborn
The pt has opted to bottle-feed her newborn. The nurse is confident that the pt has understood discharge teaching r/t breast engorgement when the pt states:
"If I experience engorgement, I should use ice to try to get some relief."
On examining a woman who gave birth 5 hrs previously, the nurse finds that the woman has saturated a perineal pad within 15 mins. What action is the nurse's 1st priority?
Palpate the woman's fundus.
The nurse is explaining to a mother who had an episiotomy how to use a Peri bottle to clean herself after urination or a bowel movement. Which info is correct?
"Use the whole Peri bottle of water to cleanse perineum."
A nurse is reinforcing teaching w/ a client who is breastfeeding and has mastitis. Which of the following statements should the nurse make?
"Completely empty each breast @ each feeding or use a pump."
A nurse is reinforcing teaching w/ a new mother on bathing a newborn. The newborn has a bluish marking across the lower back. Which of the following statements should the nurse make concerning the variation?
"This is frequently seen in newborns of African American, Asian, or Native American origin."
The nurse is trying to teach a 15 yo mother how to swaddle the baby, but the young mother seems more interested in how her hair and makeup look. She states, "My boyfriend is coming in a little while." How should the nurse respond?
"You look very pretty. He will be delighted to see you and the baby."
A nurse is caring for a client who is 2 days postpartum. The client states, "My 4 yo son was toilet trained and now he is frequently wetting himself." Which of the following responses should the nurse make?
"Your son is exhibiting an expected behavior to having a new sibling."
The newborn infant weighs 6.6 lb. How much fluid does this health baby need every day?
420-480 mL
A nurse is caring for a client who has postpartum psychosis. Which of the following actions is the nurse's priority?
Ask the client if she has thoughts of harming herself or her infant.
The mother reports a mild cramping during the postpartum period. The nurse anticipates that the HCP will write a PRN order for which med?
Acetaminophen
Newborns are not able to synthesize vitamin K in the colon until they have adequate intestinal flora. Which action would the nurse take?
Administer an injection of vitamin K (AquaMEPHYTON) as ordered.
Which TX r/t bowel function would the nurse question for a woman w/ a 4th degree laceration of the perineum?
Administer enema for constipation PRN.
A nurse is collecting data from a newborn following birth. Which of the following findings indicate the newborn is adapting to extrauterine life?
Apnea for 10-second periods Obligate nasal breathing
A woman gave birth 48 hrs ago to a healthy baby girl. She has decided to bottle feed. During the assessment, the nurse notices that both breasts are swollen, warm, and tender on palpation. The pt should be advised that this is best treated w/ which action?
Applying ice to the breasts for comfort
A nurse is caring for a newborn who was born @ 38 wks of gestation., weighs 3,200 g, and is in the 60th percentile for weight. Based on the weight and gestational age, the nurse should assign the newborn which of the following classifications?
Appropriate for gestational age
The mother reports that the new infant is making a weak, high-pitched crying sound. She has tried feeding, changing, rocking, and ignoring the baby, but the crying continues. What should the nurse do 1st?
Ask the mother to hold the baby while VS are obtained.
The nurse is performing a routine postpartum assessment. Which action is indicated before the fundal height is measured?
Ask the pt to empty her bladder.
The mother reports to the nurse that the baby doesn't seem to be getting enough breast milk. What should the nurse do 1st?
Assess how the mother places the areola in the baby's mouth.
The woman's temp is slightly elevated 12 hrs after delivery of the baby. What additional assessment would the nurse perform 1st?
Assess skin turgor and condition of mucous membranes.
The nurse hears in report that a pt who had a cesarean section should receive liquids for the 1st day w/ a gradual reintroduction to a regular diet. How does the nurse know when to offer solid foods?
Assess the abdomen and auscultate for bowel sounds.
The nurse notices that the grandmother seems to be dominating the care of her own daughter and the new infant to the point of excluding the new father. What should the nurse do?
Assess the father's feelings about his role and his knowledge of child care.
A primigravida has delivered a baby vaginally after 6 hrs of labor. She had an uneventful pregnancy and is in good general health. She is transferred from the recovery room to the postpartum unit. What interventions are included in routine postpartum care?
Assessment of intake and output until the pt is voiding in sufficient quantities Assessment of the emotional status of the new mother Checking of breasts for engorgement and cracking of nipples
When performing a postpartum assessment, what should the nurse do?
Assist the pt into a supine position w/ her arms above her head and her legs extended for the examination of her abdomen.
The nurse notes that the pt is profusely diaphoretic during the 1st night after delivery. Based on the nurse's knowledge of what is expected for the healthy mother in the immediate postpartum period, which action is the nurse most likely to take?
Assist the pt to change clothes and explain that diaphoresis is normal.
What is the most important nursing action to perform before assisting the woman to stand up and ambulate for the 1st time after the delivery of the baby?
Assist the pt to slowly sit and dangle legs while seated.
A nurse is caring for a newborn. Which of the following actions by the newborn indicates readiness to feed?
Attempts to place his hand in his mouth
When teaching parents how to bathe their baby, which point should the nurse stress?
Avoid immersing the baby in water until after the umbilical cord has fallen off.
The nurse is discussing sexuality w/ the new mother. What info should the nurse provide?
Avoid sexual activity until after the 1st postpartum office visit.
________ refers to the process whereby an infant's behavior and characteristics call forth a corresponding set of maternal behaviors and characteristics.
Bonding
The UAP tells the nurse that there was a gush of brownish vaginal drainage when the pt got out of bed and stood up. What should the nurse do 1st?
Check on the pt and assess for pain, dizziness, or continued vaginal flow.
The postpartum pt c/o a persistent headache. Which action would the nurse perform 1st?
Check the BP and compare it to baseline measurements.
When providing education to parents about care of the umbilical cord, what info should be included?
Cleaning the cord w/ an alcohol swab Keeping the diaper folded below the cord
A baby has a Gomco circumcision. What instruction should the nurse give his parents for care of the circumcised penis?
Cover the glans w/ a petroleum gauze dressing.
The pt received an epidural block. In the early recovery stage, what would be considered a normal finding?
Decreased sensation in both legs
A nurse is caring for a client who is 1 day postpartum. The nurse is checking for maternal adaptation and bonding w/ the newborn. For which of the following client behaviors should the nurse intervene?
Demonstrates apathy when the newborn cries Views the newborn's behavior as uncooperative during diaper changing
The woman is interested in returning to her prepregnant weight ASAP. She has decided to breastfeed b/c "it's better for the baby and it will also help me lose weight." What info should the nurse give to the mother about nutrition and diet?
During breastfeeding, continue the diet recommended during pregnancy.
When is infant abduction most likely to occur?
During visiting hrs
________ refers to the face-to-face position in which a parent's and infant's faces are approximately 20 cm apart and on the same plane or level.
En face
A nurse on a postpartum unit is planning to promote bonding w/ the family and siblings of a newborn. Which of the following actions should the nurse take?
Encourage the parents to explore the newborn's features.
The nurse sees that the postpartum pt has an elevation in platelet count. Based on this observation, which action will the nurse perform?
Encourage the pt to get out of bed and walk around.
________ is a term applied to a parent's absorption, preoccupation, and interest in his or her infant; the term typically is used to describe the father's intense involvement w/ his newborn.
Engrossment
A nurse is discussing risk factors for UTIs w/ a newly licensed nurse. Which of the following risk factors should the nurse include?
Epidural anesthesia Urinary bladder catheterization Frequent pelvic exams HX of UTIs
A nurse is collecting data from a newborn and observes small white nodules on the roof of the newborn's mouth. This finding is characteristic of which of the following conditions?
Epstein pearls
A nurse is preparing to administer prophylactic eye ointment to a newborn to prevent ophthalmia neonatorum. Which of the following meds should the nurse anticipate administering?
Erythromycin
The nurse helps the breastfeeding woman change her newborn's diaper after the baby's 1st bowel movement. The mother expresses concern b/c of a large amount of sticky, dark green--almost black--stool. She asks the nurse if something is wrong. What info should be included in the nurse's response?
Explain that this type of stool is called meconium and is expected for the 1st few bowel movements of all newborns.
The nurse is teaching breast care for the lactating woman. What info should be included?
Expose the nipples to air for 20-30 mins daily. Wear a supportive bra 24 hrs a day for the 1st few weeks.
A nurse is caring for a client who is in the early postpartum period and is very excited and talkative. The nurse is having difficulty completing the postpartum data collection. Which of the following actions should the nurse take?
Give the client time to express her feelings.
The nurse notes on assessing the newborn that there is a small tuft of hair at the base of the spine. What is the clinical significance of this finding?
Hair tufts indicate possible abnormalities of spinal column development.
After delivery, which pt has the greatest risk for life-threatening postpartum hemorrhage?
Has a retroperitoneal hematoma d/t rupture of cesarean scar
A nurse is evaluating the reflexes of a newborn. In checking for the Moro reflex, the nurse should perform which of the following actions?
Hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall backward.
A nurse is discussing circumcision w/ a newly hired nurse. Which of the following conditions should the nurse identify as contraindications?
Hypospadias Family HX of hemophilia Epispadias
A nurse is reinforcing teaching about proper techniques for bottle feeding w/ a new mother. Which of the following instructions should the nurse provide?
Keep the nipple full of formula throughout the feeding.
The nurse finds bright red bleeding on a pt's peripad. The stain is about 6 inches long. What is the correct description of the character and amount of lochia?
Lochia rubra, moderate
Which assessment finding in a new infant should be reported to the HCP for additional investigation?
Low-set ears
A nurse is returning a newborn to his mother following circumcision. Which of the following actions should the nurse take to ensure safety of the newborn?
Match the mother's ID band w/ the newborn's band.
A nurse on a postpartum unit is contributing to the plan of care for a client who has thrombophlebitis. Which of the following interventions should the nurse recommend?
Measure leg circumferences.
Which nursing observation of the newborn's bowel function should be reported to the HCP?
No stool is passed 24 hrs after birth
The newborn infant has a blood glucose level of 40 mg/dL. The nurse prepares for which intervention?
Oral feeding of sterile glucose water
The nurse can help a father in his transition to parenthood w/ what action?
Pointing out that the infant turned to his voice
A nurse is collecting data from a postpartum client who is exhibiting tearfulness, insomnia, lack of appetite, and a feeling of sadness. The nurse should identify these findings as an indication of which of the following conditions?
Postpartum blues
A nurse notes that the father appears nervous when the mother asks him to help care for the newborn. Which of the following actions should the nurse take to promote father-newborn bonding?
Reinforce education about newborn care when the father is present.
__________ is the phase of maternal postpartum adjustment characterized by a woman's need to review her labor and birth experiences w/ the nurse who cared for her while she was in labor. Other behaviors exhibited include reliance on others to help her meet needs, excitement, and talkativeness.
Taking-in
A baby boy is 1 hr old when admitted to the newborn nursery. He weighs 7 lb, 3 oz; is 21" long; has irregular rspirations of 42 breaths/min w/ adequate chest movement, a hr of 145 bpm, and a temp of 35.6 degrees C, axillary; and is acrocyanotic. What is an appropriate goal for this baby within the next 2 hrs, based on these findings?
Temp will stabilize @ 36.5-37 degrees C.
A woman asks the nurse how she will know her baby is getting enough milk. The nurse's response is based on understanding that which is the best determinant?
The baby has 6-10 wet diapers per day.
In evaluating maternal adjustment, which behavior leads the nurse to believe that the pt is still in the taking-in phase?
The majority of the mother's time is spent talking about her delivery experience.
A first-time mother is to be discharged from the hospital tomorrow w/ her baby girl. Which maternal behavior indicates a need for further intervention by the nurse before she can be discharged?
The mother leaves the baby on her bed while she takes a shower.
The nurse observes several interactions between a postpartum woman and her new son. Which behavior, if exhibited by this woman, does the nurse identify as maladaptive regarding parent-infant attachment?
The mother seldom makes eye contact w/ her son.
The home health nurse is assessing the mother's peripads 6 days after delivery. What is the expected finding?
Thin pinkish-brown drainage
In the postpartum period, the pt has no urge to void, but the nurse notes that the pt's bladder is distended. What complications are most associated w/ bladder distention in postpartum pts?
Uterine hemorrhage and urinary tract infections
The nurse is assessing a newborn infant who was just born @ 30 wks gestation. Which findings would be considered normal?
Vernix caseosa Lanugo Good skin turgor Good tissue elasticity
A nurse is reinforcing teaching about breastfeeding w/ the mother of a newborn. Which of the following actions indicates understanding of the teaching?
When latched on, the infant's nose, cheek, and chin are touching the mother's breast.
Normal variations in the physical characteristics of a newborn that the parents should not be alarmed in seeing are:
acrocyanosis in an infant that is 5 days old. the harlequin sign in a 2 day old infant. Epstein's pearls on the hard palate of a 2 week old infant. lacy mottling on pale skin immediately @ birth.
Care of the circumcision includes:
applying the diaper loosely.
The nurse is teaching the pt about the s/s that should be reported to the HCP. The pt is instructed to notify the HCP if, after 5 days from the delivery date, the pt experiences:
breast tenderness and redness.
The nurse identifies that the mother requires additional teaching on the care of the infant's umbilicus if she:
gives a tub bath in the 1st 3 days after delivery.
An appropriate technique to teach the new mother about the baby's bath is:
having the bathwater @ 100 degrees F (37.7 degrees C).
The mother has lost a large volume of blood and appears to be in hypovolemic shock following delivery. The nurse implements an appropriate action by:
providing oxygen by facemask @ 8-10 L/min.
In teaching the new mother about breastfeeding, the nurse informs her to:
put as much of the areolar tissue into the baby's mouth as possible.