PN4 Response of New Born

Maternal postpartum vital signs

Temp 100.4 Pulse Bradycardia 50-70 Respiration Normal 20 BP possible orthostatic hypotension

Telangiectatic nevi

"stork bites," are flat pink or red marks often seen on the eyelids, nose, or nape of the neck. These are dilated capillaries that become more vivid when the infant cries. They are not significant to the health of the infant and disappear at 1 to 2 years of age

11. On examining a woman who gave birth 5 hours previously, the nurse finds that the woman has saturated a perineal pad within 15 minutes. What action is the nurse's first priority? 1. Increase the drip rate of an IV infusion of Ringer's lactate solution. 2. Assess the patient's vital signs. 3. Call the patient's primary health care provider. 4. Palpate the woman's fundus.

4. Palpate the woman's fundus.

34. The patient received an epidural block. In the early recovery stage, what would be considered a normal finding? (848) 1. Decreased sensation in both legs 2. Altered level of consciousness 3. Elevated blood pressure compared to base-line 4. Low-grade fever

1. Decreased sensation in both legs

32. The woman is interested in returning to her prepregnant weight as soon as possible. She has decided to breastfeed because "it's better for the baby and it will also help me lose weight." What information should the nurse give to the mother about nutrition and diet? (845) 1. During breastfeeding, continue the diet recommended during pregnancy. 2. For gradual weight loss, follow MyPlate suggestions and drink 3 L of fluid each day. 3. Eliminate approximately 300-500 kcal/day for 6-8 weeks for weight loss. 4. Breastfeeding does require extra calories, so weight loss is expected.

1. During breastfeeding, continue the diet recommended during pregnancy.

21. What are normal variations in the physical characteristics of a newborn? Select all that apply. (860, 861) 1. Acrocyanosis in a 5-day-old infant 2. The harlequin sign in a 2-day-old infant 3. Jaundice during the first 24 hours after delivery 4. Epstein's pearls on the hard palate of a 2-week-old infant 5. Lacy mottling on pale skin immediately at birth

1. Acrocyanosis in a 5-day-old infant 2. The harlequin sign in a 2-day-old infant 5. Lacy mottling on pale skin immediately at birth

24. Which treatment related to bowel function would the nurse question for a woman with a fourth-degree laceration of the perineum? (837) 1. Administer stool softener for constipation as needed. 2. Assist with ambulation in hall 3 or 4 times/day. 3. Administer enema for constipation as needed. 4. Encourage fluid intake of at least 3 L/day.

1. Administer stool softener for constipation as needed.

1. A primigravida has delivered a baby vaginally after 6 hours 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? (Select all that apply.) 1. Assessment of intake and output until the patient is voiding in sufficient quantities 2. Insertion of a catheter to assess residual urine after the initial voiding 3. Firm massage of the fundus every 15 minutes 4. Assessment of the emotional status of the new mother 5. Checking of breasts for engorgement and cracking of nipples

1. Assessment of intake and output until the patient is voiding in sufficient quantities 4. Assessment of the emotional status of the new mother 5. Checking of breasts for engorgement and cracking of nipples

8. When teaching parents how to bathe their baby, which point should the nurse stress? 1. Avoid immersing the baby in water until after the umbilical cord has fallen off. 2. Use only mild medicated or scented soap. 3. Apply baby powder after the bath to keep the skin dry. 4. Apply baby oil after the bath to keep the skin soft and smooth.

1. Avoid immersing the baby in water until after the umbilical cord has fallen off.

35. The woman's temperature is slightly elevated 12 hours after delivery of the baby. What additional assessment would the nurse perform first? (847) 1. Check the appearance and odor of the lochia. 2. Assess skin turgor and condition of mucous membranes. 3. Palpate the fundus for height and firmness. 4. Check a urine specimen for foul odor and cloudiness.

1. Check the appearance and odor of the lo-chia.

9. When providing education to parents about care of the umbilical cord, what information should be included? (Select all that apply.) 1. Cleaning the cord with an alcohol swab 2. Keeping the diaper folded below the cord 3. Applying triple dye to the cord 4. Keeping the cord moist to promote healing 5. Oiling the cord to facilitate it falling off

1. Cleaning the cord with an alcohol swab 2. Keeping the diaper folded below the cord 3. Applying triple dye to the cord

4. The nurse is teaching breast care for the lactating woman. What information should be included? (Select all that apply.) 1. Expose the nipples to air for 20 to 30 minutes daily. 2. Wear a supportive bra 24 hours a day for the first few weeks. 3. Wash breasts and nipples with soap and water before each feeding. 4. Use plastic liners in bras. 5. Use ice packs every 4 hours as needed for discomfort associated with engorgement.

1. Expose the nipples to air for 20 to 30 minutes daily. 2. Wear a supportive bra 24 hours a day for the first few weeks.

23. After delivery, which patient has the greatest risk for life-threatening postpartum hemorrhage? (836) 1. Has a vaginal hematoma secondary to forceps-assisted delivery 2. Has a vulvar hematoma associated with vulvar varicosity 3. Has a vaginal hematoma related to primi-gravidity 4. Has a retroperitoneal hematoma due to rupture of cesarean scar

1. Has a vaginal hematoma secondary to forceps-assisted delivery

3. The nurse finds bright red bleeding on a patient's peripad. The stain is about 6 inches long. What is the correct description of the character and amount of lochia? 1. Lochia rubra, moderate 2. Lochia serosa, heavy 3. Lochia rubra, heavy 4. Lochia serosa, light

1. Lochia rubra, moderate

9. The nurse hears in report that the woman had a cesarean birth with general anesthesia. The combination of general anesthesia and lost abdominal tone prompts the nurse to be watchful for which potential complication? (847) 1. Paralytic ileus 2. Hyperemesis 3. Loss of sensation in legs 4. Urinary incontinence

1. Paralytic ileus

15. The nurse can help a father in his transition to parenthood with what action? 1. Pointing out that the infant turned to his voice 2. Encouraging him to go home to get some sleep 3. Taping the baby's diaper a different way 4. Suggesting that he let the baby sleep in the bassinet

1. Pointing out that the infant turned to his voice

12. A woman gave birth 48 hours 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 patient should be advised that this is best treated with which action? 1. Running warm water over her breasts during a shower 2. Applying ice to the breasts for comfort 3. Expressing small amounts of milk from the breasts to relieve pressure 4. Wearing a loose-fitting bra to prevent nipple irritation 5. Wearing a snug bra

1. Running warm water over her breasts during a shower 2. Applying ice to the breasts for comfort 5. Wearing a snug bra

13. A first-time mother is to be discharged from the hospital tomorrow with her baby girl. Which maternal behavior indicates a need for further intervention by the nurse before she can be discharged? 1. The mother leaves the baby on her bed while she takes a shower. 2. The mother continues to hold and cuddle her baby after she has fed her. 3. The mother reads a magazine while her baby sleeps. 4. The mother changes her baby's diaper, then shows the nurse the contents of the diaper.

1. The mother leaves the baby on her bed while she takes a shower.

6. In evaluating maternal adjustment, which behavior leads the nurse to believe that the patient is still in the taking-in phase? (Select all that apply.) 1. The mother states she is "starving" and can't wait to eat. 2. The majority of the mother's time is spent talking about her delivery experience. 3. The mother takes a shower and washes her hair. 4. The mother asks the nurse to teach her how to give her baby a bath. 5. The mother reports she feels as if she needs to get more rest.

1. The mother states she is "starving" and can't wait to eat. 3. The mother takes a shower and washes her hair. 5. The mother reports she feels as if she needs to get more rest.

27. In the postpartum period, the patient has no urge to void, but the nurse notes that the patient's bladder is distended. What complications are most associated with bladder distention in postpartum patients? (837) 1. Uterine hemorrhage and urinary tract infections 2. Rectocele and uterine prolapse 3. Kidney dysfunction and painful sexual intercourse 4. Urinary incontinence and perineal lacerations

1. Uterine hemorrhage and urinary tract infections

Expected head circumference

12.5-14.5 inches, ¼ of body length, 2cm larger than chest

4. The healthy newborn weighs 3.5 kg. How many kilocalories does the newborn need each day? ________ kcal/day (867)

120kcal.kg per day

The healthy neonate weighs 6.8 lbs. How much fluid does the neonate need every day? _________ mL/ day (867)

140-160ml/kg per day

18. The patient has opted to bottle-feed her new-born. Which the patient statement indicates that she understood discharge teaching related to breast engorgement? (852) 1. "I will most likely not experience breast engorgement if I manually express the milk." 2. "If I experience engorgement, I should use a covered ice pack for relief." 3. "Engorgement will most likely occur about 10 days from my delivery date." 4. "Breast engorgement is unlikely since I am not breastfeeding my baby."

2. "If I experience engorgement, I should use a covered ice pack for relief."

25. 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 information is correct? (839) 1. "First, clean perineal area front to back with toilet tissue." 2. "Use the whole Peri bottle of water to cleanse the perineum." 3. "Fill the Peri bottle with sterile water warmed to approximately 98° F (37.7° C)." 4. "Flush the perineal area twice a day for 20 minutes."

2. "Use the whole Peri bottle of water to cleanse the perineum."

10. A baby has a Gomco circumcision. What instruction should the nurse give his parents for care of the circumcised penis? 1. Soak the penis in warm water daily. 2. Cover the glans with a petroleum gauze dressing. 3. Clean the glans with alcohol to promote healing. 4. Remove any yellowish exudate that forms within 24 hours.

2. Cover the glans with a petroleum gauze dressing.

17. The nurse helps the breast-feeding woman change her newborn's diaper after the baby's first bowel movement. The mother expresses concern because of a large amount of sticky, dark green—almost black—stool. She asks the nurse if something is wrong. What information should be included in the nurse's response? 1. Tell the woman not to worry because all breast-fed babies have this type of stool. 2. Explain that this type of stool is called meconium and is expected for the first few bowel movements of all newborns. 3. Ask the woman what she ate at her last meal before giving birth. 4. Suggest that the mother ask her pediatrician to explain newborn stool patterns.

2. Explain that this type of stool is called meconium and is expected for the first few bowel movements of all newborns.

19. The nurse is assessing a newborn infant who was born at 30 weeks gestation. Which findings would be considered normal? Select all thatapply. (861) 1. Vernix caseosa 2. Lanugo 3. Desquamation 4. Good skin turgor 5. Good tissue elasticity

2. Lanugo (downy, fine hair characteristic of the fetus between 20 weeks of gestation and birth). Lanugo is most noticeable over the shoulders, forehead, and cheeks, but it is found on nearly all parts of the body, except the palms, soles, and scalp.)

26. The nurse sees that the postpartum patient has a platelet count that is on the high end of the normal range. Based on this observation, which action will the nurse perform? (848) 1. Observe the patient for fatigue, particularly after exertion. 2. Monitor temperature and watch for signs of infection. 3. Encourage the patient to get out of bed and walk around. 4. Watch for signs and symptoms of hemorrhage.

2. Monitor temperature and watch for signs of infection.

14. 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? 1. The mother talks and coos to her son. 2. The mother seldom makes eye contact with her son. 3. The mother cuddles her son close to her. 4. The mother tells visitors how well her son is feeding.

2. The mother seldom makes eye contact with her son.

22. The home health nurse is assessing the mother's peripads 6 days after delivery. What is the expected finding? (835) 1. Bright-red blood with tissue 2. Thin pinkish-brown drainage 3. Slightly yellow to white drainage 4. Small clots with a fleshy odor

2. Thin pinkish-brown drainage

20. 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 first? (871) 1. Assess the mother-child interaction to see if there are problems with bonding. 2. Try swaddling or bundling the baby to make him feel secure. 3. Ask the mother to hold the baby while vital signs are obtained. 4. Contact the pediatrician, because the cry-ing is excessive.

2. Try swaddling or bundling the baby to make him feel secure.

16. A breast-feeding mother reports to the nurse that her breasts are very firm and tender. What information should be included in the response by the nurse? (Select all that apply.) 1. "Avoiding breast-feeding for several hours will be helpful." 2. "Let's try to apply lettuce leaves to your breasts." 3. "This is known as engorgement." 4. "More frequent breast-feeding will be helpful in managing this condition." 5. "Let's take off your bra for a few hours."

3. "This is known as engorgement." 4. "More frequent breast-feeding will be helpful in managing this condition.

5. When the let-down reflex occurs, what action will the nurse perform? (834) 1. Offer the mother oral fluids to prevent de-hydration. 2. Assess the color change and consistency of the lochia. 3. Assist the mother with breastfeeding as needed. 4. Observe for frequency of saturation of perineal pads.

3. Assist the mother with breastfeeding as needed

17. The nurse is teaching the patient about the signs and symptoms that should be reported to the provider. After 5 days from the delivery date, which sign/symptom warrants contact-ing the provider? (843) 1. Temperature is 99° F. 2. Lochia is light pink-brown in color. 3. Breast is tender and red. 4. Fundus feels like a softball.

3. Breast is tender and red.

2. The nurse is performing a routine postpartum assessment. Which action is indicated before the fundal height is measured? 1. Massage the uterus. 2. Apply pressure to the fundus to check for clots. 3. Elevate the head of the bed. 4. Ask the patient to empty her bladder.

3. Elevate the head of the bed.

7. A baby boy is 1 hour old when admitted to the newborn nursery. He weighs 7 lb, 3 oz; is 21 inches long; has irregular respirations of 42 breaths/min with adequate chest movement, a heart rate of 145 beats/min, and a temperature of 35.6°C, axillary; and is acrocyanotic. What is an appropriate goal for this baby within the next 2 hours, based on these findings? 1. Color will remain unchanged. 2. Respirations will slow. 3. Temperature will stabilize at 36.5° to 37°C. 4. Heart rate will decrease to 100 beats/min.

3. Temperature will stabilize at 36.5° to 37°C.

5. 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? 1. The baby awakens every 4 to 6 hours to eat. 2. The baby stops nursing when full. 3. The baby has 6 to 10 wet diapers per day. 4. The baby cries when hungry.

3. The baby has 6 to 10 wet diapers per day.

8. What instructions would the nurse give to a mother who has elected to use bottle-feeding rather than breastfeeding? (854) 1. Pump the breasts regularly to prevent engorgement. 2. Apply warm, moist packs or shower breasts with hot water. 3. Wear a supportive bra within a few hours of delivery. 4. Decrease fluid intake to suppress milk production.

3. Wear a supportive bra within a few hours of delivery.

Term baby

37-42 weeks gestation

Large for gestational age

4,000 gms

31. The nurse hears in report that a patient who had a cesarean section should receive liquids for the first day with a gradual reintroduction to a regular diet. How does the nurse know when to offer solid foods? (845) 1. Follow the protocol or clinical pathway for cesarean section patients. 2. Give solid food when the dietary kitchen includes it on the meal tray. 3. Call the provider to clarify specific parameters. 4. Assess the abdomen and auscultate for bowel sounds.

4. Assess the abdomen and auscultate for bowel sounds.

33. What is the most important nursing action to perform before assisting the woman to stand up and ambulate for the first time after the delivery of the baby? (848) 1. Obtain a wheelchair and place it close to the bedside. 2. Assist the patient to slowly sit and dangle legs while seated. 3. Compare the blood pressure in the supine and upright positions. 4. Assist the patient to apply a pair of slippers with a nonslip sole.

4. Assist the patient to apply a pair of slippers with a nonslip sole.

15. The nurse is discussing sexuality with the new mother. What information should the nurse provide? (842) 1. Menses usually returns in 3-5 months. 2. Breastfeeding acts as an effective contraceptive. 3. Discomfort and bleeding are expected with sexual activity. 4. Avoid sexual activity until after the first postpartum office visit.

4. Avoid sexual activity until after the first postpartum office visit.

7. The nurse is monitoring the flow of lochia for several postpartum patients. Which condition is cause for the greatest concern? (835) 1. There is a gush of dark lochia as the patient gets out of bed. 2. Lochia alba changes back to lochia rubra. 3. Pad with scant lochia serosa has a fleshy smell. 4. One pad is saturated in 20 minutes with lochia rubra.

4. One pad is saturated in 20 minutes with lochia rubra. (possible hemorrhage)

The mother has lost a large volume of blood and appears to be in hypovolemic shock following the delivery. What should the nurse do first? (836) 1. Raise the head of the bed to 80 degrees. 2. Discontinue the oxytocic agent in the intra-venous infusion. 3. Massage the fundus firmly and continuously. 4. Provide oxygen by facemask at 8-10 L/ min.

4. Provide oxygen by facemask at 8-10 L/ min.

Expected weight

5-8.13lbs

Expected temperature

97.6-98.6 axillary (initial is rectal)

Expected blood pressure

Blood pressure: Apical 60-80/40-50 mm (then arm and calf)

Expected pulse

Heart rate: 120-160 (100 sleep, 120-140 awake - up to 180 crying)

Expected length

Length: 18-22cm

Expected respirations

Respirations: 30-60 (Synchronic with chest movements, may be less than 15 seconds period of apnea, obligatory nose breather)

Postterm baby

after completion of 42 weeks

Mongolian spots

areas of increased pigmentation. The lumbar dorsal area is the most common location. The area may appear bluish black. These are most often seen in darker-skinned people.

Pretrm babies

before 37 weeks gestation

Extremely low birth weight (ELBW) :

less than 1000 grams (<2.5 pounds) birth weight

Very low birth weight calssification

less than 1500 grams (3.5 pounds) birth weight

Small for gestational age

less than 2,500 gms

Low birth weight classification

less than 2500 grams (5.5 pounds) birth weight

Nevus flammeus

port-wine stain, is a reddish purple discoloration often seen on the face. This is a capillary angioma below the epidermis. Unfortunately, these do not disappear spontaneously. Medical techniques have been developed that reduce or remove port-wine birthmarks