OB Postpartum and Newborn

After birth, the nurse quickly dries and wraps the newborn in a blanket. How does this action prevent heat loss?

Evaporation

A nurse is collecting data from a client who is postpartum. Which of the following findings should alert the nurse the possibility of a postpartum complication?

Heart rate 110/min.

Surfactant is a chemical in the lungs responsible for oxygen absorption in the fetal lungs that begins to be produced at what age?

24 weeks

A nurse is caring for a postpartum client and her newborn. The client asks the nurse to feed the newborn. Which of the following responses should the nurse make?

"Feeding an infant can feel a little intimidating at first, but I'll stay with you to help."

A nurse in the nursey for a newborn. The grandmother of the newborn asks if she can take the newborn to the mother's room. Which of the following statements is an appropriate response by the nurse?

"Have the mother call and I will take the baby to the room."

A nurse is caring for a client who is postpartum. The client states, "I am concerned about my baby's hearing because my mother was born deaf." Which of the following statements should the nurse make?

"We do routine hearing screenings on newborns. You'll know the results before you leave the hospital."

A nurse is reinforcing teaching about newborn care with a client who is 2-hour postpartum. Which of the following statements by the client indicates a need for further teaching?

"my baby's temperature will be checked rectally every hour."

A nurse is reinforcing teaching with a new mother about the purpose of administering vitamin K to her newborn following delivery. The nurse should explain that the purpose of administering vitamin K is to prevent which of the following complications?

Bleeding

A nurse is assisting in the care of a newborn following birth. At 1 minute after birth, the nurse notes the following: heart rate 110/min; slow, weak cry; some flexion of extremities; grimace in response to suctioning of the nares; body pink in color with blue extremities. What should the nurse document as the newborn's 1-minute Apgar score?

6

A nurse is assisting in the care of a newborn immediately after birth. At 5 minutes after birth, the newborn has acrocyanosis of feet, flexed extremities, a grimace when suctioned. A heart rate of 130/min, and a slow weak cry. What should the nurse document as the newborn's 5-minute Apgar score?

8

A nurse is caring for a newborn who is formula fed. The newborn takes 0.5 oz of formula at 0800, 1 oz at 1100, 0.5 at 1300, 0.5 oz at 1600, and 0.5 oz at 1830. How many mL of formula should the nurse record as the client's intake for the shift?

90 mL

In what situation will the physician order RhoGAM?

An unsensitized Rh-negative mother has an Rh-positive infant.

A nurse is collecting data from a client who is 14-hour postpartum. The nurse notes: breasts soft; fundus firm, slightly deviated to the right; moderate lochia rubra; temperature 37.7℃ (100℉), pulse rate 88/min, respiratory rate 18/min. Which of the following actions should the nurse perform?

Ask the client to empty her bladder.

What should the nurse's first action be when postpartum hemorrhage from uterine stony is suspected?

Begin massaging the fundus while assessing for increase in tone.

Below what blood glucose level is the 3-hour old newborn considered hypoglycemic?

Below 40 mg/dL

A nurse is collecting data from a postpartum client and notes the client's fundus is boggy and displaced to the right. Which of the following actions should the nurse take?

Assist the client to the bathroom to void.

A nurse is collecting data from a client who is 12-hour postpartum following a spontaneous vaginal delivery. The nurse should expect to find the uterine fundus at which of the following positions on the client's abdomen?

At the level of the umbilicus or slightly above.

While inspecting a newborn's head, the nurse identifies a swelling of the scalp that does not cross the suture line. How would the nurse refer to this finding when documenting?

Cephalohematoma

nurse is caring for a client who is 4-hour postpartum. The nurse finds a small amount of lochia rubra on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

Check for blood under the client's buttock.

A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client's perineal pad. Which of the following actions should the nurse take first?

Check the client's fundus

A nurse is contributing to the plan of care for a preterm newborn. To help the newborn conserve energy, which of the following actions should the nurse recommend?

Cluster the newborn's care activities.

Meconium stool can be described as:

Dark green and tarry

A nurse is assisting with the care of a client who is in labor. Immediately after delivery of a newborn, which of the following action should the nurse take first?

Dry the newborn

A nurse is caring for a newborn immediately following delivery, after assuring patent airway with using bulb suction, which of the following actions should be the nurse's priority?

Dry the newborn

A nurse is collecting data from a newborn's immediately after delivery by a client who was at 42 weeks of gestation. Which of the following findings should the nurse expect?

Dry, cracked skin

A nurse is collecting data from a client who is postpartum 2-hour following delivery of a healthy newborn. Which of the following findings indicates the client's bladder is distended?

Elevated fundus level.

A nurse is assisting in the care of a client who is experiencing sore nipples from breastfeeding. Which of the following actions should the nurse take?

Encourage the client to change the newborn's position with each feeding.

A nurse is assisting in the care of a newborn shortly after birth. Which of the following actions should the nurse take to assist in the prevention of hyperbilirubinemia?

Initiate early feeding.

A nurse is caring for a client who is 1 day postpartum following a cesarean birth. To prevent thrombophlebitis, the nurse should contribute which of the following interventions to the client's plan of care?

Have the client ambulate frequently in the hallway.

A nurse is collecting data from a client who is 3-hour postpartum. The nurse notes that the client's fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus. Which of the following actions should the nurse take?

Have the client urinate.

A nurse is preparing to examine a post-term newborn immediately following delivery. Which of the following findings should the expect to observe? (Select all that apply.)

Hypoglycemia Cracked, peeling skin

In report the labor and delivery note the infant has been displaying signs of hypoglycemia. You as the nurse understand to look for: (select all that apply).

Lethargy Tremors Weak cry

Identify in the picture pad #2. What type of lochia would you chart?

Light, < 4-inch stain

Your patient's preterm infant has been admitted to the special care nursery unit. The mother asks you what they will be watching her baby for in the special care unit that the newborn nursery can not give him. You the nurse recognize the special care unit will monitor the preterm infant for the following: select all that apply:

Maintain body heart Closely monitored Prevent infection Improve respiration

A nurse is caring for a postpartum client who saturates a perineal pad in 10 minutes. Which of the following actions should the nurse take first?

Massage the client's fundus.

Identify the newborn reflex.

Moro reflex

What will the nurse expect when assessing the anterior fontanelle of a healthy, full-term newborn?

Open and diamond shaped

Massage and putting the infant to the breast of a postpartum patient have been ineffective in controlling a boggy uterus. What will the nurse anticipate might be ordered by the physician?

Oxytocin

A nurse is reviewing the medical record of a client who experienced a vaginal birth 2-hour age. The nurse should identify that which of the following findings places the client at risk for a postpartum hemorrhage?

Precipitous birth

When assessing a perineum of c-section suture line the nurse should use the acronym REEDA. REEDA stands for:

Redness, Edema, Ecchymosis, Discharge, Approximation

What type of lochia will the nurse assess initially after delivery that can last up the 3 days?

Rubra

A nurse is caring for a client at risk for giving birth to a newborn who has a neural tube defect. Which of the following assessment findings would indicate the malformation?

Spina bifida

What is the first sign of hypovolemic shock from postpartum hemorrhage?

Tachycardia

A nurse is caring for a client who is breastfeeding and tells the nurse that she is concerned about her newborn's hydration. Which of the following nursing observations is appropriate to discuss with the mother in evaluating the adequacy of the newborn's hydration?

The number of wet diapers per day.

A nurse is caring for a newborn. How many blood vessels should the nurse expect to observe in the newborn's umbilical cord?

Two arteries and one vein (AVA)