woman 2

How does the nurse position the infant experiencing respiratory difficulty?

Positioning the infant on the back allows bilateral lung expansion. Elevating the head 15 degrees enhances movement of the diaphragm. Positioning the infant on the side or on the stomach restricts lung expansion.

The nurse is educating a client who is breastfeeding her 2-week-old newborn regarding the nutritional requirements of newborns, according to the recommendations of the American Academy of Pediatrics (AAP). Which response by the mother would validate her understanding of the information she received?

"I will give him vitamin D supplements daily for the first 2 months of life."

A client is Rh-negative and has given birth to her newborn. What should the nurse do next?

Determine the newborn's blood type and rhesus.

When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply.

Help the mother initiate breastfeeding within 30 minutes of birth. Encourage breastfeeding of the newborn infant on demand. Place baby in uninterrupted skin-to-skin contact with the mother.

Transthoracic echocardiography

Non-invasive ultrasound test used to measure ejection fraction and examine size, shape, and motion of cardiac structures.

A woman gave birth vaginally approximately 12 hours ago, and her temperature is now 100.8° F (38.2° C). Which action would be most appropriate for the nurse to take?

Notify the health care provider about this elevation; this finding reflects infection. A temperature above 100.4° F (38° C) at any time or an abnormal temperature after the first 24 hours may indicate infection and must be reported.A temperature of 100.4° F or less during the first 24 hours postpartum is normal and may be the result of dehydration due to fluid loss during labor.

A nurse is assessing a term newborn and finds the blood glucose level is 23 mg/dl. The newborn has a weak cry, is irritable, and exhibits bradycardia. Which intervention is most appropriate?

The infant is demonstrating signs and symptoms of significant hypoglycemia. IV dextrose should be administered to the term newborn intravenously when the blood glucose level is less than 40 mg per dL, and the newborn is symptomatic for hypoglycemia. Administration of IV glucose assists in stabilizing blood glucose levels. Providing oral glucose feedings or placing the infant on a radiant warmer will not help maintain the glucose level. Monitoring the infant's hematocrit level is not a priority and not related to the problem at hand.

A nurse is caring for a client with idiopathic thrombocytopenic purpura (ITP). Which intervention should the nurse perform first?

administration of platelet transfusions as prescribed

A new mother tells the nurse at the baby's 3 month check-up, "When she cries, it seems like I am the only one who can calm her down." This is an example of which behavior?

attachement

Caput succedaneum

diffuse edema of the fetal scalp that crosses the suture lines. reabsorbes within 1 to 3 days

A nurse is providing care to a postpartum woman. Documentation of a previous assessment of a woman's lochia indicates that the amount was moderate. The nurse interprets this as reflecting approximately how much?

scant: a 1- to 2-in (2.5- to 5-cm) lochia stain on the perineal pad or approximately a 10-mL loss; light or small: an approximately 4-in (10-cm) stain or a 10- to 25-mL loss; moderate: a 4- to 6-in (10- to 15-cm) stain with an estimated loss of 25 to 50 mL; large or heavy: a pad saturated within 1 hour after changing it or over 50-mL loss.

A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first?

venous duplex ultrasound of the right leg

A nurse is assessing a preterm newborn. The nurse determines that the newborn is comfortable and without pain based on which finding?

The newborn may be in pain if the following are exhibited: sudden high-pitched cry; facial grimace with furrowing of brown and quivering chin; increased muscle tone; oxygen desaturation; body posturing, such as squirming, kicking, and arching; limb withdrawal and thrashing movements; increase in heart rate, blood pressure, pulse, and respirations; fussiness and irritability.

During the newborn's assessment, which finding would lead the nurse to suspect that a large-for-gestational-age newborn has experienced birth trauma?

asymmetrical movement

All of the following are ways the nurse can encourage bonding between the parents and the newborn except:

telling the mother that the best way to bond with her baby is to breastfeed.

Rho(D) immune globulin is administered to which clients? Select all that apply.

An Rh-negative woman who had a spontaneous abortion yesterday An Rh-negative woman following an ectopic pregnancy A Rh negative woman who gives birth at 32 weeks gestation to a baby with A+ blood

The hospital is providing a class on newborn care to a group of parents prior to their discharge with their newborns. Which statement by a parent would indicate that further teaching is needed? You Selected:

If our baby turns red in the face and strains to have a stool that means she is constipated." Straining and turning red in the face when having a stool is not indicative of constipation.

The nurse, assessing the lochia of a client, attempts to separate a clot and identifies the presence of tissue. Which observation would indicate the presence of tissue?

If tissue is identified in the lochia, it is difficult to separate clots. Yellowish-white lochia indicates increased leukocytes and decreased fluid content. Easily separable lochia indicates the presence of clots only. Foul-smelling lochia indicates endometritis.

A client who gave birth by cesarean birth 3 days ago is bottle-feeding her neonate. While collecting data the nurse notes that vital signs are stable, the fundus is four fingerbreadths below the umbilicus, lochia are small and red, and the client reports discomfort in her breasts, which are hard and warm to touch. The best nursing intervention based on this data would be:

encouraging the client to wear a supportive bra. Hard, warm breasts indicate engorgement, which occurs approximately 3 days after birth. Vital signs are stable and do not indicate signs of infection. The client should be encouraged to wear a supportive bra, which will help minimize engorgement and decrease nipple stimulation. Ice packs can reduce vasocongestion and relieve discomfort. Warm water and a breast pump will stimulate milk production.

Assessment of a newborn reveals microcephaly. The nurse recognizes that this newborn may also have which complications? Select all that apply.

infants with microcephaly are also noted to have additional complications such as epilepsy, cerebral palsy, intellectual disability, and ophthalmologic and hearing disorders. Hydrocephalus and achondroplasia are more commonly seen with macrocephaly.

Which result of a biophysical profile would indicate to the nurse that the fetus might tolerate labor poorly? Select all that apply.

low amniotic fluid placenta grada 3

A nursing student learns that a certain condition occurring in up to 3 in every 1,000 births is a major cause of death. What is this condition?

pulmonary embolism

venogram

radiographic image of a vein (after an injection of contrast media)

Hypercoagulability during pregnancy

stasis (compression of the large veins because of gravid uterus), altered coagulation (state of pregnancy), and localized vascular damage (may occur during birthing process)

Which is the best place to perform a heel stick on a newborn?

the fat pads on the lateral aspects of the foot

The nurse is caring for a newborn of a mother with human immunodeficiency virus (HIV). What is the priority for the nurse to complete following delivery?

Bathe the newborn thoroughly

A neonate is being admitted to the observational nursery with the diagnosis of postmaturity. What would the nurse expect to find with this gestational age variation? Select all that apply.

Postterm newborns typically exhibit peeling skin, with vernix caseosa and lanugo being absent. The creases will cover the entire soles of the feet. The umbilical cord will be thin, and there will be limited vernix and lanugo. There will be meconium-stained skin and fingernails evident with a thin umbilical cord.

Prevention and early identification of newborns at risk are necessary nursing functions. A nurse anticipates the need for newborn resuscitation secondary to birth asphyxia based on which prenatal risk factors? Select all that apply.

Prenatal risk factors that can help identify the newborn that may need resuscitation include maternal history of substance use disorder, gestational hypertension, fetal distress due to hypoxia before birth, chronic maternal diseases, maternal or perinatal infection, placental problems, umbilical cord problems, difficult or traumatic birth, multiple births, congenital heart disease, maternal anesthesia or recent analgesia, or preterm or postterm birth

The nurse in a newborn nursery is observing for developmentally appropriate care. Which is an example of self-regulation?

Self-regulation is a form of self-soothing for an infant such as sucking on hands or putting hand to mouth type of movements.

During an extended initial resuscitation, what additional complications may be experienced by the infant during the resuscitation? Select all that apply

The stress may cause accelerated metabolism of glucose stores and hypoglycemia. Dehydration may occur due to insensible water loss during ventilation and other resuscitative procedures. Hypokalemia, anemia, and leukoctosis are not complications during an initial resuscitation.

When assessing the uterus of a 2-day postpartum client, which finding would the nurse evaluate as normal?

a moderate amount of lochia rubra The client should have lochia rubra for 3 to 4 days postpartum. The client would then progress to lochia serosa being expelled from day 3 to 10. Last the client would have lochia alba from day 10 to 14 until 3 to 6 weeks.

The nurse has been asked to conduct a class to teach new mothers how to avoid developing stress incontinence. Which actions would the nurse include in her discussion as possible strategies for the new mothers to do? Select all that apply.

a regular program of Kegel exercises; losing weight, if necessary; avoid smoking; limiting intake of alcohol and caffeinated beverages; and adjusting the fluid intake to produce a 24-hourly output of 1,000 mL to 2,000 mL.

A client has come to the office for her first postpartum visit. On evaluating her blood work, the nurse would be concerned if the hematocrit is noted to have:

acutely decreased. Despite the decrease in blood volume, the hematocrit remains relatively stable and may even increase, reflecting the predominant loss of plasma. An acute decrease in hematocrit is not an expected finding and may indicate hemorrhage.

In a class for expectant parents, the nurse may discuss the various benefits of breastfeeding. However, the nurse also describes that there are situations involving certain women who should not breastfeed. Which examples would the nurse cite? Select all that apply.

antithyroid drugs, antineoplastic drugs, alcohol, and street drugs. Also women who are HIV positive should not breastfeed. Other contraindications include inborn error of metabolism or serious mental health disorders in the mother that prevent consistent feeding schedules.

What action by the nurse provides the neonate with sensory stimulation of a human face?

assisting the mother to position the infant in an enface position To allow the infant to see a human face, assist the mother to assume an enface position with the infant. Mother and child need to be in the same plane and about 6 to 10 inches (15 to 25 cm) apart. Looking through the isolette dome or porthole distorts the image. Infants need to see objects within 12 inches (30 cm) to focus clearly.

A new mother has been reluctant to hold her newborn. Which action by the nurse would help promote this mother's attachment to her newborn?

bringing the newborn into the room.

A nurse is assisting a postpartum client out of bed to the bathroom for the first time. Which interventions would be most appropriate? Select all that apply.

checking blood pressure first before ambulating the client; elevating the head of the bed for a few minutes before ambulating the client; having the client sit on the side of the bed for a few moments before getting up; helping the client to stand up, and staying with her; ambulating alongside the client and providing support if needed; and frequently asking the client how her head feels.

A newborn does not breathe spontaneously at birth. The nurse administers oxygen by bag and mask. If oxygen is entering the lungs, the nurse should notice that the:

chest rises with each bag compression.

The nurse notices while holding him upright that a day-old newborn has a significantly indented anterior fontanelle. She immediately brings it to the attention of the primary care provider. What does this finding indicate?

dehydration

Which maternal factors should the nurse consider contributory to a newborn being large for gestational age? Select all that apply.

diabetes mellitus postdates gestation prepregnancy obesity

The nurse is reviewing the medical record of a postpartum client. The nurse determines that the client is at risk for thromboembolism based on which factors from her history? Select all that apply.

oral contraceptive use, multiparity, age over 35 years, severe varicose veins, and preeclampsia.

The nurse is caring for several women in the postpartum clinic setting. Which statement(s), when made by one of the clients, would alert the nurse to further assess that client for postpartum psychosis? Select all that apply.

"The newborn is not really mine emotionally, since I was never pregnant and do not have children." "When the newborn is sleeping, I can see his thoughts projected on my phone and I do not like the thoughts." "I believe my newborn is losing weight because I will not feed him because my milk was poisoned by the health care provider."

A postpartal woman with an episiotomy asks the nurse about perineal care. Which recommendation would the nurse give?

A suture line should be kept free of lochia to discourage infection. Washing with soap and water at the time of a shower will help to do this.

A newborn is receiving ampicillin and gentamicin every 12 hours. When would this client have his hearing screen performed?

After the newborn has completed the antibiotic therapy

Which safety precautions should a nurse take to prevent infection in a newborn? Select all that apply.

Avoid coming to work when ill. Use sterile gloves for an invasive procedure. Initiate universal precautions when caring for the infant.

Which client-satisfaction related intervention of staff nurses may lead to improved client outcomes?

Bedside reports build the client's trust, enhance teamwork, and protect safety. Hourly rounding is recommended. The nurse manager should round daily.

A nurse is caring for a postpartum client diagnosed with von Willebrand disease. What should be the nurse's priority for this client?

Check the lochia. The nurse should assess the client for prolonged bleeding time. von Willebrand disease is a congenital bleeding disorder, inherited as an autosomal dominant trait, that is characterized by a prolonged bleeding time, a deficiency of von Willebrand factor, and impairment of platelet adhesion.

Which condition may cause intrauterine asphyxia? Select all that apply.

Conditions such as cord compression, placenta abruption, and intrauterine growth restriction alter uteroplacental blood flow and may cause intrauterine asphyxia. Gestational diabetes may cause fetal hyperinsulinemia, and group B strep infection may cause intrauterine infection or PROM/preterm labor.

What is the correct sequence of events in a neonatal resuscitation?

Dry the infant, establish an airway, expand the lungs, and initiate ventilation.

A neonate has an injury to the brachial plexus. Which of the following conditions is a result of a brachial plexus injury?

Erb palsy. Injury to the brachial plexus results in Erb palsy or a paralysis of the arm caused by injury to the upper group of the arm's main nerves.

In an effort to decrease complications for the infant right after birth, the nurse would expect to administer which medication for prophylaxis of potential eye conditions?

Erythromycin or tetracycline ophthalmic ointment is the agent of choice for newborn eye prophylaxis

A new mother talking to a friend states, "I wish my baby was more like yours. You are so lucky. My baby has not slept straight through the night even once. It seems like all she wants to do is breastfeed. I am so tired of her." This is an example of which behavior?

Expressing disappointment or displeasure in the infant, failing to explore the infant visually or physically, and failing to claim the infant as part of the family are just a few examples of negative attachment behaviors.

A postpartum woman is experiencing subinvolution. When reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify? Select all that apply.

Factors that inhibit involution include prolonged labor and difficult birth, uterine infection, overdistention of the uterine muscles such as from hydramnios, a full bladder, close childbirth spacing, and incomplete expulsion of amniotic membranes and placenta. Breast-feeding, early ambulation, and an empty bladder would facilitate uterine involution.

A client is diagnosed with a puerperal infection. The nurse is most correct to provide which instruction?

Finish all antibiotics to decrease a genital tract infection. A puerperal infection is an infection of the genital tract after delivery through the first 6 weeks postpartum. It is most important to include finishing all antibiotics in nursing instructions.

A nurse is assessing a client with postpartal hemorrhage; the client is presently on IV oxytocin. Which interventions should the nurse perform to evaluate the efficacy of the drug treatment? Select all that apply.

Get a pad count. Monitor the client's vital signs. Assess the client's uterine tone.

The nurse is assessing a small-for-gestational age (SGA) newborn, 12 hours of age, and notes the newborn is lethargic with cyanosis of the extremities, jittery with handling, and a jaundiced, ruddy skin color. The nurse expects which diagnosis as a result of the findings?

Newborns born small for gestational age (SGA) are at risk for polycythemia. They should therefore undergo screening at 2, 12, and 24 hours of age. Observe for clinical signs of polycythemia (respiratory distress, cyanosis, jitteriness, jaundice, ruddy skin color, and lethargy).

The new mother has decided to feed her infant formula. When teaching her about the different types of formula, the nurse should stress the infant should receive how many calories each day?

Newborns need about 108 cal/kg or approximately 650 cal/day. Therefore, they will need 2 to 4 ounces at each feeding to feel satisfied. Until about 6 months, most bottle-fed infants need six feedings a day.

A preterm infant has an umbilical vessel catheter inserted so that blood can be drawn readily. Which would be most important to implement during this procedure?

Preterm infants must be protected from chilling during all procedures, because maintaining warmth is a major concern because of immaturity.

A preterm infant will be hospitalized for an extended time. Assuming the infant's condition is improving, which environment would the nurse feel is most suitable for the child?

Provide a mobile the child can see no matter how the child is turned.

An 18-year-old client has given birth in the 28th week of gestation, and her newborn is showing signs of respiratory distress syndrome (RDS). Which statement is true for a newborn with RDS?

Respiratory distress syndrome (RDS) is a serious breathing disorder caused by a lack of alveolar surfactant. Betamethasone, a glucocorticosteroid, is often given to the mother 12 to 24 hours before a preterm birth to help reduce the severity of RDS, not to the newborn following birth. Respiratory symptoms in the newborn with RDS typically worsen within a short period of time after birth, not improve. Diagnosis of RDS is made based on a chest X-ray and the clinical symptoms of increasing respiratory distress, crackles, generalized cyanosis, and heart rates exceeding 150 beats per minute (not below 50 beats per minute).

A client who has given birth is being discharged from the health care facility. She wants to know how safe it would be for her to have intercourse. Which instructions should the nurse provide to the client regarding intercourse after birth?

Resume intercourse if bright red bleeding stops.

The nurse is caring for a client who underwent a cesarean birth 24 hours ago. Which assessment finding indicates the need for further action?

The fundus is located 2 fingerbreadths above the umbilicus. The fundus should be in the midline position and at or just below the level of the umbilicus. The client is encouraged to ambulate. Requiring assisting is not problematic at this stage of the recovery period. The absence of a temperature elevation is also normal.

A newborn is receiving bag and mask ventilation and cardiac compression. The resuscitation is paused, and the nurse reassesses the infant. The infant's heart rate is 70 bpm with irregular gasping respirations. What is the appropriate action in this situation?

The infant is exhibition respiratory distress and needs continued bag and mask resuscitation. The heart rate is greater than 60 bpm, so cardiac compressions are not needed.

A client in her sixth week postpartum reports general weakness. The client has stopped taking iron supplements that were prescribed to her during pregnancy. The nurse would assess the client for which condition?

The nurse should assess the client for hypovolemia as the client must have had hemorrhage during birth and puerperium. Additionally, the client also has discontinued iron supplements. Hyperglycemia can be considered if the client has a history of diabetes. Hypertension and hyperthyroidism are not related to discontinuation of iron supplements.

The newborn nursery nurse is admitting a small-for-gestational-age (SGA) infant and is reviewing the maternal history. What factor in the maternal history would the nurse correlate as a risk factor for a SGA infant?

The nurse should perform a thorough physical examination of the newborn and closely observe the newborn for typical SGA characteristics, which include the following: a newborn head that is disproportionately large compared with rest of body; a wasted appearance of extremities with reduced subcutaneous fat stores; a reduced amount of breast tissue; poor muscle tone over buttocks and cheeks; and a thin umbilical cord.

A nurse is assessing the fluid status of a preterm newborn. Which parameter would be most appropriate for the nurse to assess?

When assessing the fluid status of a preterm newborn, the nurse palpates the fontanels. Sunken fontanels suggest dehydration; bulging fontanels suggest overhydration.

The nurse is providing education to a postpartal woman who has developed a uterine infection. Which statement by the woman indicates that further instruction is needed?

With a uterine infection, the client needs to be in a semi-Fowler position to facilitate drainage and prevent the infection from spreading. Changing the perineal pads regularly, walking to promote drainage, and contacting the doctor if her uterus becomes rigid or she notes a decrease in urinary output are all correct actions.

On a routine home visit, the nurse is asking the new mother about her breastfeeding and personal eating habits. How many additional calories should the nurse encourage the new mother to eat daily?

additional 500 calories per day, 20 grams of protein per day, 400 mg of calcium per day, and 2 to 3 quarts of fluid per day. Reference:

Nevus flammeus is usually benign, but can be associated with what syndrome?

also called a port wine stain, may be associated with structural malformations, bony or muscular overgrowth, and certain childhood cancers and should be monitored with periodic examinations

All infants need to be observed for hypoglycemia during the newborn period. Based on the facts obtained from pregnancy histories, which infant would be most likely to develop hypoglycemia?

an infant who had difficulty establishing respirations at birth

Which condition may cause intrauterine asphyxia? Select all that apply.

cord compression placenta abruption intrauterine growth restriction

The data analysis phase consists of the following essential components:

grouping and organizing data, validating data and comparing the data with norms, clustering data to make inferences, generating possible hypotheses regarding the client's problems, formulating a professional clinical judgment, and validating the judgment with the client.

A client has given birth to a small-for-gestation-age (SGA) newborn. Which finding would the nurse expect to assess?

head larger than body Head being larger than the rest of the body is the characteristic feature of small for gestational age infants. Small for gestational age infants weigh below the 10th percentile on the intrauterine growth chart for gestational age. The heads of SGA infants appear larger in proportion to their body. They have an angular and pinched face and not a rounded and flushed face. Round flushed face and protuberant abdomen are the characteristic features of large for gestational age (LGA) infants. Preterm infants, and not SGA infants, are covered with brown lanugo hair all over the body.

After an extended resuscitation, the infant's body temp is 35.8°C. What assessment finding would the nurse anticipate as a consequence of a temperature of 35.8°C? Select all that apply.

heart murmur hypoglycemia decreasing oxygen saturation

A premature, 38-week-gestation neonate is admitted to the observational nursery and placed under bili-lights with evidence of hyperbilirubinemia. Which assessment findings would the neonate demonstrate? Select all that apply.

increased serum bilirubin levels clay-colored stools tea-colored urine

During the fourth stage of labor, the nurse assesses the client's fundal height and tone. When completing this assessment, the nurse performs which action to prevent prolapse or inversion of the uterus?

places a gloved hand just above the symphysis pubis

A nurse is providing care to a postpartum woman and is completing the assessment. Which finding would indicate to the nurse that a postpartum woman is experiencing bladder distention?

A distended bladder is dull on percussion and can be palpated as a rounded mass. In addition, the uterus would be boggy, and lochia would be more than usual.

The LVN/LPN will be assessing a postpartum client for danger signs after a vaginal birth. What assessment finding would the nurse assess as a danger sign for this client?

A fever more than 100.4° F (38° C) is a danger sign that the client may be developing a postpartum infection. Lochia rubra is a normal finding as is a firm uterine fundus. A uterine fundus above the umbilicus may indicate that the client has a full bladder but does not indicate a postpartum infection.

The nurse in the NICU is caring for preterm newborns. Which guidelines are recommended for care of these newborns? Select all that apply.

Controlling the temperature of preterm newborns is often difficult; therefore, special care should be taken to keep these babies warm. Nurses should dress them in a stockinette cap, take their temperature often, and supply oxygen, if necessary. To conserve the energy of small newborns, the nurse should handle them as little as possible. Usually, they will not give them a bath immediately. Parents should be encouraged to bond with their infants.

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?

Copious diaphoresis occurs in the first few days after childbirth as the body rids itself of excess water and waste via the skin. The excessive diaphoresis is not caused by changes in hormones, nor because of the client drinking too much fluid, nor because of the body trying to rid itself of the excess blood made during pregnancy.

Methylergonovine is prescribed for a woman experiencing postpartum hemorrhage. The nurse monitors the woman closely for which adverse effects?

Seizures, hypertension, uterine cramping, nausea, vomiting, and palpitations are adverse effects of methylergonovine. Uterine hyperstimulation is an adverse effect of oxytocin. Flushing and headache are adverse effects of carboprost.

One hour after birth the nurse is assessing a neonate in the nursery. The nurse begins by assessing which parameters?

The nurse begins by assessing the neonate's posture, color, and respiratory effort. These three parameters provide a general overview of the infant's condition and adaptation to extrauterine life. Skin condition and birthmarks as well as head and chest circumference are part of the comprehensive physical and are documented within the first day of life. Bowel sounds are not present until about 15 minutes after birth and the infant may not void until 24 hours of age. Reference:

A nurse is caring for an infant. A serum blood sugar of 40 was noted at birth. What care should the nurse provide to this newborn?

The nurse should provide some nutrition to any infant born with hypoglycemia. Dextrose should be given intravenously only if the infant refuses oral feedings, not before offering the infant oral feedings. Placing the infant on a radiant warmer will not help maintain blood glucose levels. The nurse should focus on decreasing blood viscosity in an infant who is at risk for polycythemia, not hypoglycemia.

A nurse initiates bag and mask ventilation with an anesthesia bag on a newborn with no spontaneous respiratory effort. What controls the pressure of breaths delivered by an anesthesia bag?

The pressure exerted by the nurse's hand squeezing the bag controls the pressure delivered by an anesthesia bag. An ambu or resusci bag has a blow-off value that limits the pressure administered.

The nurse is monitoring several postpartum women for potential complications related to the birthing process. Which assessment should a nurse prioritize on an hourly basis?

The way to monitor for bleeding every hour is to assess pads and percentage of the pad saturated by blood in the previous hour. It would not be necessary to do a complete blood count every hour, nor hourly urines. Vital signs are not typically taken every hour.

A nurse helps a postpartum woman out of bed for the first time postpartally and notices that she has a very heavy lochia flow. Which assessment finding would best help the nurse decide that the flow is within normal limits?

A typical lochia flow on the first day postpartally is red; it contains no large clots; the uterus is firm, indicating that it is well contracted.

A nurse is assessing a woman during the first 24 hours after birth. Which assessment finding would the nurse determine as acceptable during this time? Select all that apply.

Fundus one fingerbreadth below the umbilicus Moderate saturation of peripad every 3 hours. A fundus should be one fingerbreadth below the umbilicus at 24-hours postpartum, and moderate saturation of two-thirds of the pad is appropriate. Inverted nipples always require intervention if breastfeeding. Hypotonic bowel sounds also require assessment more frequently than routinely ordered, and urination of100 mL every 4 hours is inadequate given the occurrence of diuresis.

Which intervention would be helpful to a bottle-feeding client who is experiencing hard or engorged breasts?

Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids does not reduce engorgement and should not be encouraged. Warm compresses will promote blood flow and hence, milk production, worsening the problem of engorgement. Bromocriptine has been removed from the market for lactation suppression.

The nurse is teaching a client with newly diagnosed mastitis about her condition. The nurse would inform the client that she most likely contracted the disorder from which organism?

Staphylococcus aureus

A female 1-day-old newborn's temperature is 97.1℉ (36.2℃) in an open crib and the newborn has been in the mother's room for several hours. What action should the nurse take? Select all that apply.

The newborn's temperature is low and she needs to be warmed up. Placing a cap on her head and wrapping her in a blanket helps the newborn conserve body heat. Determining the maternal room temperature is important to ensure that the newborn was not chilled while out with the mother, and helps determine the cause of the hypothermia. Lastly, placing the crib away from walls and drafts will help prevent heat loss and maintain a thermoneutral environment.

Which assessment by the nurse will best monitor the nutrition and fluid balance in the postterm newborn?

The nurse should assess for a decrease in urinary output and fluid balance in the preterm or postterm newborn. Weight of the newborn should be measured daily, not once every 2 to 3 days. Increased muscle tone does not indicate nutrition and fluid imbalance. A rise, not fall, in temperature indicates dehydration.

During a routine home visit, the couple asks the nurse when it will be safe to resume full sexual relations. Which answer would be the best?

There is no set time to resume sexual intercourse after birth; each couple must decide when they feel it is safe. Typically, once bright red bleeding has stopped and the perineum is healed from the episiotomy or lacerations, sexual relations can be resumed. This is usually by the third to sixth week postpartum.

A nurse is assessing the vital signs of a woman who delivered a healthy newborn vaginally 2 hours ago. Which temperature reading would lead the nurse to notify the health care provider?

Typically, the new mother's temperature during the first 24 hours postpartum is within the normal range or a low grade elevation. Some women experience a slight fever, up to 100.4°F (38.0°C), during the first 24 hours. However, A temperature above 100.4°F (38.0°C) at any time or an abnormal temperature after the first 24 hours may indicate infection and must be reported.

A postpartum woman has been unable to urinate since giving birth. When the nurse is assessing the woman, which finding would indicate that this client is experiencing bladder distention?

Uterus is boggy. A distended bladder is dull on percussion and can be palpated as a rounded mass. In addition, the uterus would be boggy and lochia would be more than usual.

Prior to discharge is an appropriate time to evaluate the client's status for preventative measures such as immunizations and Rh status. Which test would the nurse ensure has been conducted to evaluate the Rh negative mother?

indirect Coombs' test