Reproduction: Postpartum Newborn and Complications

Rubin identified a series of changes that a new mother makes during the postpartum period. The correct sequence of these changes is: - taking, holding-on, letting-go - taking-in, holding-on, letting-go - taking-in, taking-hold, letting-go - taking-in, taking-on, letting go

taking-in, taking-hold, letting go

A nurse is preparing to assess a newborn immediately after birth using the Apgar score. Which area would the nurse include in this assessment? Select all that apply. - Respiratory effort - Color - Heart rate - Blood pressure - Muscle tone

- respiratory effort - color - heart rate - muscle tone

The nurse records a newborn's Apgar score at birth. A normal 1-minute Apgar score is: - 1 to 2. - 5 to 9. - 7 to 10. - 12 to 15.

7 to 10

A nurse is describing to a group of young parents the many changes that will occur during the early postpartum period. The nurse reviews common reports experienced as the woman's body returns to her prepregnancy state. The nurse determines that the teaching was successful when the participants identify which report as being most common during the first week (indicating that fluid volume is returning to normal)? - diaphoresis - nocturia - urinary frequency - urinary urgency

diaphoresis

The healthcare provider has delivered a newborn and hands the child to the nurse. Which action should a nurse perform immediately? - Aspirate mucus from the neonate's nose and mouth. - Dry the neonate to stabilize the child's temperature. - Administer vitamin K. - Place antibiotic ointment in the eyes.

dry the neonate to stabilize the child's temperature

When providing postpartum teaching to a couple, the nurse correctly identifies what time as when pathologic jaundice may be found in the newborn? - during the first 24 hours of life - between 2 and 4 days of life - after 5 days postpartum - often with formula-fed babies

during the first 24 hours of life

A nurse is preparing for a class to teach pregnant women and their partners about postpartum complications. Which measure would be most important for the nurse to emphasize as helping to prevent postpartum infection? - hand washing - limiting contact with outsiders for the first week - ensure proper hydration - adequate follow up with their health care provider

hand washing

An obese woman with diabetes has just given birth to a term, large-for-gestational-age (LGA) newborn. Which condition should the nurse most expect to find in this infant? - hypoglycemia - hyperglycemia - hypotension - hypertension

hypoglycemia

The nurse is providing teaching to the mother of a newborn with early jaundice about the condition's progression. The nurse knows that the teaching regarding hyperbilirubinemia was successful when the mother makes which response? - "Kernicterus is a consequence of elevated bilirubin levels and has possible lifelong effects." - "My baby should not get hyperbilirubinemia if I place him near a window in the sun light." - "My baby will be 3 days old at discharge, and I will not need to worry about hyperbilirubinemia." - "Since I'm exclusively breastfeeding, the risk of my baby having hyperbilirubinemia is very low."

kernicterus is a consequence of elevated bilirubin levels and has possible lifelong effects

Based on the nurse's knowledge about the postpartum period and an increase in blood coagulability during the first 48 hours, the nurse closely assesses the client for which condition? - hyperglycemia - varicose veins - thromboembolism - calcium depletion

thromboembolism

What is the primary rationale for monitoring a new mother every 15 minutes for the first hour after delivery? - to monitor the mother's blood pressure to note any elevation - to check for postpartum hemorrhage - to determine if the mother's milk is coming in - to answer questions the new parents may have

to check for postpartum hemorrhage

After a class for expectant parents on the various forms of birth control after the birth of their infant, the nurse realizes more training is needed when a participant makes which comment? - "I'm going to be breastfeeding occasionally, so we won't need to use any other birth control for at least six months." - "We will be discussing birth control with our primary care provider to find the best method for us." - "We're going to use a barrier for the first few months and then decide what we want to do." - "I'm going back on the pill as soon as the doctor okays it."

I'm going to be breastfeeding occasionally, so we won't need to use any other birth control for at least six months

The nurse is caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would the nurse need to assess before the woman ambulates? - attachment, lochia color, complete blood cell count - blood pressure, pulse, reports of dizziness - degree of responsiveness, respiratory rate, fundus location - height, level of orientation, support system

blood pressure, pulse, reports of dizziness

If the nurse manages a newborn with low blood sugar, which intervention would be appropriate to prevent hypoglycemia? - Hold all feedings. - Check the heart rate. - Feed the neonate. - Give antibiotics.

feed the neonate

A mother asks the nurse why her newborn is getting a Vitamin K injection in the birth room. The nurse explains that the injection is necessary because: - Vitamin K is needed for coagulation, and the newborn does not produce vitamin K in the few days following birth. - Vitamin K aids in protein metabolism. Newborns have defective protein metabolism until 24 hours of life. - Newborns are prone to hypoglycemia, and vitamin K helps maintain a steady blood glucose level. - The mother was febrile at the time of birth and prophylactic vitamin K is necessary.

vitamin K is needed for coagulation, and the newborn does not produce vitamin K in the few days following birth

Which sign would indicate dehydration in a newborn? - frequent feedings - eight wet diapers a day - sunken fontanels (fontanelles) - 10% weight gain

sunken fontanels (fontanelles)

When caring for a newborn several hours after birth, the nurse assesses the newborn's respiratory rate. In a normal newborn, this would be: - 12 to 16 breaths per minute. - 16 to 20 breaths per minute. - 20 to 30 breaths per minute. - 30 to 60 breaths per minute.

30 to 60 breaths per minute

The nurse receives a report from labor and delivery on an infant and mother couplet. Which reported Apgar score will the nurse prioritize for close observation for the entire transition period? - 8 at 1 minute; 9 at 5 minutes - 7 at 1minute; 8 at 5 minutes - 6 at 1 minute; 7 at 5 minutes - 5 at 1 minute; 6 at 5 minutes

5 at 1 minute; 6 at 5 minutes

Four weeks before the birth of a client's already large child, the health care provider has told the client that if the baby gets bigger and the baby's lungs are ready, a cesarean birth is preferred. The woman asks the nurse what the downside is to having a cesarean rather than a vaginal birth. What is an appropriate response by the nurse? - "If the health care provider has recommended the procedure, it's likely that the benefits outweigh the risks." - "The procedure isn't risky for the baby, but your healing takes longer, and you'll have a scar." - "As the baby passes through the birth canal some of the excess fluid is expelled from the lungs; if that doesn't happen there's a higher risk of respiratory distress." - "Some women don't have any problem giving birth to large babies. You might want to get a second opinion."

as the baby passes through the birth canal some of the excess fluid is expelled from the lungs; if that doesn't happen there's a higher risk of respiratory distress

A nurse coming onto the night shift assesses a client who gave birth vaginally that morning. The nurse finds that the client's vaginal bleeding has saturated two perineal pads within 30 minutes. What is the first action the nurse should take? - Ask the client to get out of bed and try to urinate. - Call the physician for a methylergonovine order. - Assess the fundus and massage it if it's boggy. - Give the client a new pad and check her in 30 minutes.

assess the fundus and massage if it's boggy

The nurse is assisting a client who has just undergone an amniocentesis. Blood results indicate the mother has type O blood and the fetus has type AB blood. The nurse should point out the mother and fetus are at an increased risk for which situation related to this procedure? - placental abruption (abruptio placentae) - preterm birth - baby developing hemolytic anemia - baby developing postbirth jaundice

baby developing postbirth jaundice

The nurse is admitting a 10-pound (4.5-kg) newborn to the nursery. What is important for the nurse to monitor during the transition period? - Apgar score - blood sugar - heart rate - temperature

blood sugar

The nurse has admitted a small-for-gestational-age infant (SGA) to the observation nursery from the birth room. Which action would the nurse prioritize in the newborn's care plan? - Closely monitor temperature. - Assess for hyperglycemia. - Monitor intake and output. - Observe feeding tolerance.

closely monitor temperature

The nurse is caring for a large-for-gestational-age newborn (also known as macrosomia). What maternal condition is the usual cause of this condition? - alcohol use - hypertension - celiac disease - diabetes

diabetes

Which action would be priority for the nurse to complete immediately after the delivery of a 40-week gestation newborn? - Swaddle the infant and place in the bassinet. - Complete a full head-to-toe assessment. - Assess the newborn's glucose level. - Dry the newborn and place it skin-to-skin on mother.

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

A nurse is assessing a newborn for jaundice. The nurse would first notice jaundice at which area? - face - trunk - legs - arms

face

The parents of a premature newborn infant ask why their child needs to remain under a warming light. On what information does the nurse base the answer? - Newborn hypothermia comes from conduction to the bedding materials. - Full-term newborns have brown fat, which is used to generate heat. - All newborns have difficulty maintaining thermoregulation. - Lack of insulin delays carbohydrate metabolism in newborns.

full-term newborns have brown fat, which is used to generate heat

A newborn that has a surfactant deficiency will have which assessment noted on a physical exam? - regular respirations - pink skin - hypertension - grunting

grunting

A nurse is assessing a client on the second postpartum day. Upon palpation, the nurse discovers that the fundus is deviated to the right. To further investigate this finding, what should the nurse ask the client? - are you having afterpains - have you voided recently - when did you last change your perineal pad - do you have any uterine tenderness

have you voided recently

When assessing a neonate 1 hour after birth, the nurse notes acrocyanosis of both feet and hands, measures an axillary temperature of 95.5°F (35.3°C), an apical pulse of 110 beats/minute, and a respiratory rate of 64 breaths/minute. Which assessment would be the most concerning for the nurse? - hypothermia - tachycardia - bradypnea - hypoxia

hypothermia

A postpartum client is ready for discharge. Which client statement reflects an understanding of the teaching session? - i will call my physician if my episiotomy hurts - i should notify my physician if the vaginal discharge changes to a whitish color after 2 weeks - i will call my physician if i notice redness, warmth, and pain in my breasts - i should call my physician if i have a temp of 99.2 F for 24 hours or more

i will call my physician if i notice redness, warmth, and pain in my breasts

A nurse is caring for a preterm newborn born at 29 weeks' gestation. Which nursing diagnosis would have the highest priority? - Grieving related to the loss of "a healthy full-term newborn" - Ineffective thermoregulation related to decreased amount of subcutaneous fat - Risk for injury related to the very thin epidermis layer of skin - Imbalanced nutrition: Less than body requirements related to the premature digestive system

ineffective thermoregulation related to decreased amount of subcutaneous fat

While examining a 2-day old newborn, a nurse notices that the skin and sclera of the eyes appear yellow. The nurse recognizes this condition as: - jaundice. - cyanosis. - pallor. - harlequin sign.

jaundice

What would the nurse expect to prioritize in the assessment of a newborn who has a positive Coombs test? - tremor activity - hyperglycemia - jaundice development - phenylketonuria

jaundice development

A nurse is assessing the parent-neonate attachment of postpartum clients. Which finding most indicates a need for further evaluation? - parental desire to room-in with the neonate - limited parent-neonate contact immediately after birth - parental understanding of the importance of parent-neonate bonding - previous cesarean birth

limited parent-neonate contact immediately after birth

In the preterm newborn, the most critical complications are related to which system? - respiratory - digestive - immune - integumentary

respiratory

A neonate born by elective cesarean birth weighs 7 lb, 3 oz (3,267 g). The nurse closely monitors for which assessment finding related to a complication from this type of birth? - fluctuating body temperature - respiratory distress - peripheral and circumoral cyanosis - fluctuating blood glucose results

respiratory distress

A nurse is discussing breastfeeding with a new mother and demonstrates that when she strokes the baby's cheek, the baby turns his head in that direction. This movement is known as which reflex? - rooting reflex - extrusion reflex - Moro reflex - Babinski reflex

rooting reflex

When giving a postpartum client self-care instructions in preparation for discharge, the nurse instructs her to report heavy or excessive bleeding. How should the nurse describe "heavy bleeding?" - saturating 1 pad in 3 hours - saturating 1 pad in 1 hour - saturating 1 pad in 6 hours - saturating 1 pad in 8 hours

saturating 1 pad in 1 hour

A 1-day-old newborn is being examined by the nurse practitioner, who makes the following notation: face and sclera appear mildly jaundiced. What causes this finding? - The breakdown of RBCs release bilirubin, which the liver cannot excrete. - The GI tract is immature, so the bilirubin remains in the intestines. - The newborn's Vitamin K levels are low. - Feedings are not adequate to eliminate the build-up of bilirubin.

the breakdown of RBCs release bilirubin, which the liver cannot excrete

Which assessment finding within the first 24 hours of birth requires immediate health care provider notification? - The skin is jaundiced. - Milia is noted on the nose. - The neonate slept for 18 hours. - The neonate ate 1 to 2 oz of formula.

the skin in jaundiced

A nurse is teaching a postpartum client how to perform Kegel exercises. Which client statement indicates an understanding of the purpose of these exercises? - "These exercises help to prevent urine retention." - "The exercises may help to relieve lower back pain." - "I can use these exercises to strengthen the abdominal muscles." - "These exercises help to strengthen the perineal muscles."

these exercises help to strengthen the perineal muscles

During pregnancy, a woman's cardiovascular system expands to care for the growing fetus. After birth, during the early postpartum period, the woman eliminates the additional fluid volume she has been carrying. What is one way she does this? - Urinary elimination - Elimination of solid wastes - Being too tired to eat - Breathing off fluid vapor

urinary elimination

While visiting a client at home on the 10th day postpartum, the nurse assesses the client's lochia. Which color would the nurse expect the lochia to be? - red - pink - yellowish white - yellowish pink

yellowish white

A newborn is born and, at 1 minute of life, is acrocyanotic, HR is 110, is floppy with some flexion, has a weak cry and grimaces. What Apgar score would the nurse assign this infant? - 6 - 7 - 8 - 9

6

A newborn has a heart rate of 90 beats per minute, a regular respiratory rate of 40 breaths per minute, tight flexion of the extremities, a grimace when stimulated, and acrocyanosis. The nurse assigns an Apgar score of: - 5. - 6. - 7. - 8.

7

A newborn develops physiologic jaundice, and the mother asks the nurse why this happened. Which response by the nurse would be most accurate? - "Because his liver is a bit immature, the baby can't break down the bilirubin as fast as needed." - "There is some type of blood incompatibility between you and your baby that's causing the problem." - "Your baby must have a blocked duct near his liver that's preventing the bilirubin from being excreted." - "We really don't know why jaundice develops in some babies and not in others. We just know how to treat it."

because his liver is a bit immature, the baby can't break down the bilirubin as fast as needed

A client who is 3 days postpartum calls the office and complains of excessive night sweats. Which explanation should the nurse provide for the client? - change in pregnancy hormone - body secreting - the patient may be drinking too much fluid - the body is trying to get rid of the extra blood made during pregnancy

body secreting the excess fluids from pregnancy

During assessment of the mother during the postpartum period, what sign should alert the nurse that the client is likely experiencing uterine atony? - firm fundus - foul-smelling urine - purulent vaginal drainage - boggy or relaxed uterus

boggy or relaxed uterus

The nurse is teaching new parents the best way to prevent hypothermia. Which mechanism would the nurse include when explaining about the newborn's primary method of heat production? - nonshivering thermogenesis - thermoconduction - thermoregulation - shivering thermogenesis

nonshivering thermogenesis

The nurse is documenting the relationship between a postpartum mother and her infant. Which observation would demonstrate attachment? - the infant is in the crib every time the nurse goes into the room - the infant remains in the nursery most of the day - the father is always holding the infant - the mom is talking to the infant while breastfeeding the infant

the mom is talking to the infant while breastfeeding the infant

A nurse is caring for a pregnant client who is HIV positive. What is a priority issue that the nurse should discuss with the client? - the client's relationship with the spouse - the amount of physical contact that should occur with the infant - the client's plan for future pregnancies - the need for the client to avoid breastfeeding

the need for the client to avoid breastfeeding

Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage? - hemoglobin level of 12 g/dl (120 g/L) - uterine atony - thrombophlebitis - moderate amount of lochia rubra

uterine atony

The nursery head nurse is conducting a staff in-service on prevention of hypoglycemia. What information would she share with this group? Select all that apply. - If a newborn becomes lethargic or sleepy, draw a heel stick blood glucose. - Offer glucose feedings to all newborns at 1 hour of age. - Encourage breastfeeding mothers to nurse immediately after delivery. - Keep the newborns warm in the nursery and covered with a blanket. - Initiate early feedings for all bottle-fed newborns.

- encourage breastfeeding mothers to nurse immediately after delivery - keep the newborns warm in the nursery and covered with a blanket - initiate early feedings for all bottle-fed newborns

A nurse is caring for an infant born with an elevated bilirubin level. When planning the infant's care, what interventions will assist in reducing the bilirubin level? Select all that apply. - Increase the infant's hydration. - Stop breastfeeding until jaundice resolves. - Offer early feedings. - Administer vitamin supplements. - Initiate phototherapy.

- increase the infant's hydration - offer early feedings - initiate phototherapy

Which of the following actions would the nurse perform if the nurse suspects the complication of thrombophlebitis in the leg in a postpartum woman? Select all that apply. - prepare the client for venous doppler ultrasound - assess vital signs - prepare for administration of tissue plasminogen activator (TPA) - place client on bed rest - administer estrogen for lactation suppression

- prepare the client for venous doppler ultrasound - assess vital signs - place client on bed rest

The nurse is teaching a postpartum woman and her spouse about postpartum blues. The nurse would instruct the couple to seek further care if the client's symptoms persist beyond which time frame? - 1 week - 2 weeks - 3 weeks - 4 weeks

2 weeks

A 35-year-old client has just given birth to a healthy newborn during her 43rd week of gestation. What should the nurse expect when assessing the condition of the newborn? - meconium aspiration in utero or at birth - seizures, respiratory distress, cyanosis, and shrill cry - yellow appearance of the newborn's skin - tremors, irritability, and high-pitched cry

meconium aspiration in utero or at birth

A nurse is providing care for a postpartum client. Which condition increases this client's risk for a postpartum hemorrhage? - hypertension - uterine infection - placenta previa - severe pain

placenta previa

The nurse has administered erythromycin ointment to a newborn. What outcome indicates this nursing intervention has been effective? - The newborn's active eye infection resolves. - The newborn does not contract ophthalmia neonatorum. - The newborn's sclerae do not appear yellow. - The newborn is about to produce sufficient tears.

the newborn does not contract ophthalmia neonatorum

A newborn has a 5-minute Apgar score of 9. What intervention should the nurse take for this client? - Actively stimulate the infant to cry. - Offer blow-by oxygen. - Wrap the infant in a blanket and hand to the mother for bonding. - Place the infant in a warmer bed and heat the newborn up.

wrap the infant in a blanket and hand to the mother for bonding

A nursing student observes that the babies in the nursery are wrapped up warmly and are wearing knit caps. Which explanation by the nursery staff would be correct? - "The caps and blankets simulate the temperature of the mother's womb that they are used to." - "Newborns lose body heat easily and need to be kept warm until their body temperature stabilizes." - "Studies show that newborns like the extra warmth." - "That's how we have always done it, and it seems to work out well."

newborns lose body heat easily and need to be kept warm until their body temperature stabilizes

The nurse is interacting with a young mother and her 2-week-old infant. Which behavior by the mother should the nurse prioritize and report to the RN or health care provider? - talking to the infant and rocking the infant - not responding to the infant crying -discussing her birth with another new mom - breast-feeding the infant in public

not responding to the infant crying

A nurse is caring for a 5-hour-old newborn. The primary care provider has asked the nurse to maintain the newborn's temperature between 97.7° F and 99.5° F (36.5° C and 37.5° C). Which nursing intervention would be the best approach to maintaining the temperature within the recommended range? - Delay weighing the infant, as the scales may be cold. - Use the stethoscope over the newborn's garment. - Place the newborn's crib close to the outer wall in the room. - Place the newborn skin-to-skin (kangaroo care) with the mother.

place the newborn skin-to-skin (kangaroo care) with the mother

A nurse is reviewing a postpartum woman's history and labor and birth record. The nurse determines the need to closely monitor this client for infection based on which factor? - labor less than 3 hours - hemoglobin of 11.5 mg/dl (115 g/L) - placenta removed via manual extraction - multiparity

placenta removed via manual extraction

When palpating for fundal height on a postpartum woman, which technique is preferable? - placing one hand at the base of the uterus, one on the fundus - placing one hand on the fundus, one on the perineum - resting both hands on the fundus - palpating the fundus with only fingertip pressure

placing one hand at the base of the uterus, one on the fundus

The father of a 2-week-old infant presents to the clinic with his disheveled wife for a postpartum visit. He reports his wife is acting differently, is extremely talkative and energetic, sleeping only 1 or 2 hours at a time (if at all), not eating, and appears to be totally neglecting the infant. The nurse should suspect the client is exhibiting signs and symptoms of which disorder? - postpartum blues - postpartum depression - postpartum psychosis - maladjustment

postpartum psychosis

A woman who had a cesarean birth of twins 6 hours ago reports shortness of breath and pain in her right calf. What complication should the nurse expect? - infection - hemorrhage - pulmonary emboli - fluid volume overload

pulmonary emboli

Which instruction would the nurse include in the teaching plan for a postpartum woman with mastitis? - "Stop breastfeeding until the pain and swelling subside." - "You'll need to take this medication to stop the milk from being produced." - "Try applying warm compresses to your breasts to encourage the milk to be released." - "Limit the amount of fluid you drink so your breasts don't get much fuller."

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

A nurse is assigned to care for a newborn with an elevated bilirubin level. Which symptom would the nurse expect to find during the infant's physical assessment? - yellow sclera - abdominal distention - heart rate of 130 bpm - respiratory rate of 24 breaths/minute

yellow sclera