Postpartum and Newborn prepu

During the admission assessment of a female neonate, a nurse notes a large lump on the neonate's head. Concerned about making the correct assessment, the nurse differentiates between caput succedaneum and a cephalohematoma based on the knowledge that caput succedaneum occurs primarily with primigravidas. caput succedaneum occurs primarily with a prolonged second stage of labor. a cephalohematoma occurs with a birth that required instrumentation. a cephalohematoma doesn't cross the suture lines. SUBMIT ANSWER

a cephalohematoma doesn't cross the suture lines.

A nurse visits a client at home on the 10th postpartum day. When assessing the client's uterus, which finding requires further evaluation? a nonpalpable fundus in the abdomen lochia alba a fundus palpable at the umbilicus minimal afterpains when nursing

a fundus palpable at the umbilicus

The health care provider (HCP) prescribes an intramuscular injection of vitamin K for a term neonate. The nurse explains to the mother that this medication is used to prevent which problem? hypoglycemia hyperbilirubinemia hemorrhage polycythemia

hemorrhage

A nurse is teaching a postpartum client who has decided to breast-feed her neonate. She has questions regarding her nutritional intake and wants to know how many extra calories she should eat. What number of additional calories should the nurse instruct the client to eat per day? Record your answer using a whole number.

500

After a lengthy labor, a primigravid client gives birth to a healthy newborn boy with a moderate amount of skull molding. What information would the nurse include when explaining to the parents about this condition? It is unusual when the brow is the presenting part. Surgical intervention may be necessary to alleviate pressure. It is typically seen with breech births. It usually lasts a day or two before resolving.

It usually lasts a day or two before resolving.

A nurse is caring for a client in the fourth stage of labor. Based on the nurse's note, which postpartum complication has the client developed? Uterine rupture. Puerperal infection. Mastitis. Postpartum hemorrhage. Deep vein thrombosis (DVT).

Postpartum hemorrhage.

A neonate born by elective cesarean birth weighs 7 lb, 3 oz. (3,267 g). The nurse places the neonate under the warmer unit. In addition to routine assessments, the nurse should closely monitor this neonate for which sign? Signs of acrocyanosis Unstable blood sugars Respiratory distress caused by lack of contractions Temperature instability resulting from the type of birth

Respiratory distress caused by lack of contractions

A term neonate's mother is O-negative, and cord studies indicate that the neonate is A-positive. Which finding indicates that the neonate developed hemolytic disease? Signs of kernicterus Frequent feeding patterns Increased activity Weight loss of less than 10%

Signs of kernicterus

A nurse is teaching the parents of a newborn about the timing of fontanel closure. The nurse explains that the anterior fontanel closes by age 18 months. Indicate on the illustration (view figure) the location of the anterior fontanel.

diamond shape

What site should the nurse use to obtain a blood sample to screen a neonate for phenylketonuria (PKU)? heel scalp vein brachial artery radial artery

heel

While assessing a male neonate whose mother desires him to be circumcised, the nurse observes that the neonate's urinary meatus appears to be located on the ventral surface of the penis. The health care provider (HCP) is notified because the nurse suspects which complication? epispadias phimosis hydrocele hypospadias

hypospadias

The nurse is assessing a neonate born to a mother with type 1 diabetes. Which finding is expected? hypertonia large size scaly skin hyperactivity

large size

A nurse completes postpartum assessments on every shift. Which parameters should the nurse include in the assessment? Select all that apply. bowel sounds complete blood count lochia appetite fundus bladder

lochia fundus bowel sounds bladder

A nurse assesses a client's vaginal discharge on the first postpartum day and describes it in the progress note (shown above). Which terms best identifies the discharge? (red) lochia rubra lochia serosa lochia lochia alba

lochia rubra

Which observation is expected when the nurse is assessing the gestational age of a neonate born at term? sole creases covering the entire foot ear lying flat against the head square window sign angle of 90 degrees absence of rugae in the scrotum

sole creases covering the entire foot

A mother is instructed to stimulate the rooting reflex when attempting to breast-feed her baby. Which action shows that the mother understands these instructions? turning the neonate's head to the side, causing the neonate to extend the extremities on that side initiating the neonate's startle reflex to make sure the baby is aware stroking the neonate's cheek giving the neonate water to check for swallowing

stroking the neonate's cheek

Which finding would the nurse expect as common for a multiparous client giving birth to a viable neonate at 41 weeks' gestation with the aid of a vacuum extractor? neonatal intracranial hemorrhage cephalohematoma maternal lacerations caput succedaneum

caput succedaneum

A breastfeeding primiparous client who gave birth 8 hours ago asks the nurse, "How will I know that my baby is getting enough to eat?" Which guideline should the nurse include in the teaching plan as evidence of adequate intake? regain of lost birth weight by the third day six to eight wet diapers by the fifth day three to four transitional stools on the fourth day ability to fall asleep easily after feeding on the first day

six to eight wet diapers by the fifth day

Which assessment finding should a nurse interpret as abnormal for a 38-week gestation neonate who is 1 hour old? blue hands and feet black and blue spots on the neonate's buttocks slight yellowish hue to the skin enlargement of the mammary glands

slight yellowish hue to the skin

Twenty-four hours after a client has given birth, the nurse documents that involution is progressing normally after palpating the client's fundus at which location? barely above the upper margin of the symphysis pubis slightly above the level of the umbilicus slightly below the level of the umbilicus midway between the umbilicus and the symphysis pubis

slightly below the level of the umbilicus

What would the nurse expect to find during the physical examination of a preterm male neonate born at 28 weeks' gestation? numerous scrotal rugae descended testicles abundance of scalp hair thin, wasted appearance

thin, wasted appearance

Which finding is considered normal in the neonate during the first few days after birth? birth weight of 4½ to 5½ lb (2,000 to 2,500 g) weight loss then return to birth weight weight gain of 25% weight loss of 25%

weight loss then return to birth weight

When caring for a post partum client, the student nurse correctly recalls which expected progression of lochia? Rubra, then serosa, then alba Rubra,then alba, then serosa Serosa, then rubra, then alba Serosa, then alba, then rubra

Rubra, then serosa, then alba

A postpartum client tells the nurse she is constipated. Which response by the nurse is best? "Eating more cheese will provide you with calcium which is important to breastfeeding moms" "Maintain bed rest and avoid exercise while your body is healing the constipation with naturally resolve" "Add more fruits, vegetables and fluid to each meal" "Limit fluid intake to 32 oz (1 L) daily"

"Add more fruits, vegetables and fluid to each meal"

A primiparous client planning to breastfeed her term neonate born vaginally asks, "When will my 'real' milk come in?" The nurse explains to the client that after birth, breasts begin to produce milk within what time period? 12 hours 7 days 24 hours 2 to 4 days

2 to 4 days

A postpartum client gave birth 6 hours ago without anesthesia and just voided 100 ml. The nurse palpates the fundus two fingerbreadths above the umbilicus and off to the right side. What should the nurse do first? Catheterize the client. Reassess in 1 hour. Obtain a prescription for a fluid bolus. Administer ibuprofen.

Catheterize the client.

The nurse is assessing a newborn (view the figure). What should the nurse expect the infant to do? Extend the arms. Close the fingers around the nurse's hands. Lift the torso. Turn the head to the left side.

Close the fingers around the nurse's hands

A nurse is assessing a neonate born 1 day ago to a client who smoked one pack of cigarettes daily during pregnancy. Which finding is most common in neonates whose mothers smoked during pregnancy? Postterm birth Small size for gestational age Appropriate size for gestational age Large size for gestational age

Small size for gestational age

How should a nurse assess a neonate's rooting reflex? Touch the neonate's lips. Place an object in the neonate's palm. Stroke the neonate's cheek. Stroke the sole of the neonate's foot.

Stroke the neonate's cheek.

The student nurse correctly anticipates which lochial findings in a client within the first 24 hours after birth? Vaginal discharge is a foul odor. Vaginal discharge contains large clots or tissue fragments. Vaginal discharge consists of bright red blood. There is no vaginal dischage at all

Vaginal discharge consists of bright red blood.

What should the nurse expect to find in a premature female neonate born at 30 weeks' gestation who is small for gestational age? elbows brought to chest midline with resistance past the midline prominent creases on the soles and heels fine, downy hair over the upper arms and back firm cartilage to the edge of the ear pinna

fine, downy hair over the upper arms and back

After teaching a mother about the neonate's positive Babinski's reflex, the nurse determines that the mother understands the instructions when she says that a positive Babinski's reflex indicates which factor? possible injury to nerves that innervate the legs possible partial paralysis possible spinal cord defect immaturity of the central nervous system

immaturity of the central nervous system

A nurse is eliciting reflexes in a neonate during a physical examination. Identify the area that the nurse would touch to elicit a plantar grasp reflex.

toes

A nurse assesses a 1-day-old neonate. Which finding indicates respiratory distress? acrocyanosis respiratory rate of 54 breaths/minute nasal flaring abdominal breathing

nasal flaring

After explaining to a primiparous client about the causes of her neonate's cranial molding, which statement by the mother indicates the need for further instruction? "The amount of molding is related to the amount and length of pressure on the head." "The molding was caused by an overlapping of the baby's cranial bones during my labor." "Brain damage may occur if the molding does not resolve quickly." "The molding will usually disappear in a couple of days."

"Brain damage may occur if the molding does not resolve quickly."

A nurse places a neonate with hyperbilirubinemia under a phototherapy lamp, covering the eyes and gonads for protection. The parents asked the nurse to tell them how their baby will benefit from having phototherapy done. Which statement by the nurse is the most appropriate response about phototherapy? "Phototherapy promotes respiratory stability." "Phototherapy increases the baby's iron level." "Phototherapy decreases the serum unconjugated bilirubin level." "Phototherapy prevents hypothermia." SUBMIT ANSWER

"Phototherapy decreases the serum unconjugated bilirubin level."

The triage nurse in the pediatrician's office returns a call to a mother who is breastfeeding her 4-day-old infant. The mother is concerned about the yellow seedy stool that has developed since discharge home. What is the best reply by the nurse? "The stool results from the gassy food eaten by the mother. Refrain from eating these foods while breastfeeding." "The stool will transition into a soft, brown, formed stool within a few days and is appropriate for breastfeeding." "Soft and seedy unformed stools with each feeding are normal for this age and will continue through breastfeeding." "This type of stool indicates the infant may have diarrhea and should be seen in the office today."

"Soft and seedy unformed stools with each feeding are normal for this age and will continue through breastfeeding."

While changing the neonate's diaper, the client asks the nurse about some red-tinged drainage from the neonate's vagina. Which response would be most appropriate? "It's of no concern because it's such a small amount." "The cause is usually related to swallowing blood during the birth." "Sometimes baby girls have this from hormones received from the mother." "This vaginal spotting is caused by hemorrhagic disease of the newborn."

"Sometimes baby girls have this from hormones received from the mother."

While the nurse is conducting a teaching session on breast-feeding, a client asks why she should put her newborn to the breast within the first 30 minutes of birth. The nurse's best response will be "Breast-feeding will prevent the newborn from heat loss." "Your breasts will be firm and filled with colostrum at this time." "Breast-feeding will inhibit prolactin production." "The neonate will be responsive and eager to suck at this time."

"The neonate will be responsive and eager to suck at this time."

Which instructions should the nurse give to a client after noting a white, cheese-like substance on the neonate's body creases? Clean the area with alcohol. Brush it off with a dry washcloth. Allow it to remain on the skin. Remove it with hand lotion.

Allow it to remain on the skin.

On the second postpartum day after a cesarean birth, the client reports having gas pains. What should the nurse should instruct the client to do? Chew on some ice chips. Ask the primary care provider for a simethicone prescription. Drink some hot coffee. Ambulate more often.

Ambulate more often.

A male neonate underwent circumcision. What nursing intervention is part of the initial care of a circumcised neonate? Apply alcohol to the site. Apply petroleum gauze to the site for 24 hours. Keep the neonate in the supine position. Change the diaper as needed.

Apply petroleum gauze to the site for 24 hours.

The nurse is assessing a client who is 4 hours postpartum. Based on the findings documented by the nurse, which action is most appropriate at this time? Call the client's primary healthcare provider for direction. Raise the head of the bed. Notify the charge nurse of the assessment findings. Straight-catheterize the client for half of her urine volume. Ask the client to empty her bladder. Notify the charge nurse of the assessment findings

Ask the client to empty her bladder.

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? Give the client a new pad and check her in 30 minutes. Assess the fundus and massage it if it's boggy. Call the physician for a methylergonovine order. Ask the client to get out of bed and try to urinate.

Assess the fundus and massage it if it's boggy.

While assisting a primiparous client with her first breastfeeding session, the nurse should instruct the mother to perform which action in order to stimulate the neonate to open the mouth and grasp the nipple? Brush the neonate's lips lightly with the nipple. Place the nipple into the neonate's mouth on top of the tongue. Squeeze both of the neonate's cheeks simultaneously. Pull down gently on the neonate's chin and insert the nipple.

Brush the neonate's lips lightly with the nipple.

A nurse is caring for a woman who gave birth to her baby boy 2 hours ago. The nurse notes the woman's perineal pad contains some small clots and a moderate amount of lochia has accumulated under her buttocks. What is the first action the nurse should take at this time? Measure blood loss by measuring perineal pad. Perform an in-and-out catheter immediately. Request a prescription to administer oxytocin. Check fundus for position and consistency.

Check fundus for position and consistency.

On examination of a Black newborn, the nurse notes a macular, blue-black area of pigmentation near the buttocks. Which nursing action is appropriate? Consider the finding as normal in a Black client. Put a dressing over the pigmented area. Inform the health care provider about the condition. Ask the mother about any complications in pregnancy.

Consider the finding as normal in a Black client.

Which action is most appropriate when noting small, shiny white specks on the neonate's gums and hard palate during assessment? Attempt to obtain a sterile specimen on a swab. Try to remove the specks with a wet washcloth. Continue monitoring because these spots are normal. Place the neonate in an isolation area.

Continue monitoring because these spots are normal.

Twelve hours after a vaginal birth with epidural anesthesia, the nurse palpates the fundus of a primiparous client and finds it to be firm, above the umbilicus, and deviated to the right. What should the nurse do next? Contact the health care provider (HCP) for a prescription for oxytocin. Encourage the client to ambulate to the bathroom and void. Document this as a normal finding in the client's record. Gently massage the fundus to expel the clots.

Encourage the client to ambulate to the bathroom and void.

The nurse has assisted a multigravida with a precipitous birth of a term neonate. Because a precipitous birth can lead to decreased uterine tone, what nursing action should help to prevent this complication? Massage the client's fundus continuously. Encourage the mother to breastfeed the infant. Place the mother in a supine position. Place the neonate on the client's fundus.

Encourage the mother to breastfeed the infant.

During the immediate postpartum period after giving birth to twins, the client experiences uterine atony. What should the nurse do first? Increase the intravenous fluid rate. Assess the client for infection. Determine if the uterus has ruptured. Gently massage the fundus.

Gently massage the fundus

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 the nurse accidentally bumps the bassinet, the neonate throws out its arms, hands opened, and begins to cry. The nurse interprets this reaction as indicative of which reflex? grasping reflex Moro reflex Babinski reflex tonic neck reflex

Moro reflex

The nurse is caring for a client 24 hours postpartum from a normal, vaginal delivery, and identifies which assessment finding and requiring immediate intervention? Patient reports pain and warmth behild left knee Patient reports feeling chilled and cold Patient reports feeling warm and flushed Patient reports feeling too excited to sleep

Patient reports pain and warmth behild left knee

A multiparous client whose fundus is firm and midline at the umbilicus 8 hours after a vaginal birth tells the nurse that when she ambulated to the bathroom after sleeping for 4 hours, her dark red lochia seemed heavier. Which information would the nurse include when explaining to the client about the increased lochia on ambulation? The increased lochia needs to be reported to the health care provider (HCP) immediately. The increase in lochia may be an early sign of postpartum hemorrhage. The increased lochia occurs from lochia pooling in the vaginal vault. This increase in lochia usually indicates retained placental fragments.

The increased lochia occurs from lochia pooling in the vaginal vault.

A nurse is performing a psychosocial assessment on a first-time mother and her neonate. Which behavior indicates a need for further evaluation? The mother pays more attention to the neonate than to the nurse. The mother holds the neonate close to her. The mother speaks to the neonate in a soft tone. The mother makes little eye contact with the neonate.

The mother makes little eye contact with the neonate.

When developing a teaching plan for the parents of a neonate who is to receive phototherapy, the nurse should give the parents which information? Select all that apply. Their baby's eyes will be covered. The vital signs will need to be monitored frequently. The baby will need have the body covered at all times. They will be able to visit and care for their baby. Their baby will be fed through an orogastric tube.

Their baby's eyes will be covered. The vital signs will need to be monitored frequently. They will be able to visit and care for their baby.

A new primiparous client asks the nurse, "Can my baby see?" Which statement about neonatal vision should the nurse include in the explanation? Usually they see clearly by about 2 days after birth. They can see objects up to 12 inches (30.5 cm) away. Neonates primarily focus on moving objects. Neonates primarily distinguish light from dark.

They can see objects up to 12 inches (30.5 cm) away.

The nurse has been assigned to care for several postpartum clients and their neonates on a birthing unit. Which client should the nurse assess first? a primiparous client at 48 hours after cesarean birth of a term neonate a multiparous client at 48 hours postpartum who is being discharged a multiparous client at 24 hours postpartum whose infant is in the special care nursery a primiparous client at 2 hours postpartum who gave birth to a term neonate vaginally

a primiparous client at 2 hours postpartum who gave birth to a term neonate vaginally

On the first postpartum day after a cesarean birth, the client is prescribed a full liquid diet as tolerated. Before providing a full liquid breakfast, the nurse should assess which factor? desire to eat breath sounds degree of pain bowel sounds

bowel sounds

A 3-day-old neonate is receiving phototherapy with an overhead bilirubin light to treat jaundice. What measure should the nurse include in the plan of care? Turn the neonate every 6 hours. Notify the primary care provider if the skin becomes bronze in color. Encourage the mother to discontinue breastfeeding. check the vital signs every 2 to 4 hours.

check the vital signs every 2 to 4 hours.

A nurse completes the initial assessment of a newborn. According to the due date on the antenatal record, the baby is 12 days postmature. Which of the following physical findings contradicts the estimated gestational age of the newborn? hypoglycemia absence of lanugo increased amounts of vernix meconium aspiration

increased amounts of vernix

When preparing to obtain a neonatal screening test for phenylketonuria (PKU), the nurse understands that the neonate must have been fed what to ensure reliable results? initial formula or breast milk at least 24 hours before the test a feeding of an iron-rich formula nothing by mouth for 4 hours before the test a feeding of glucose water

initial formula or breast milk at least 24 hours before the test

A multigravid client in active labor at 39 weeks' gestation has a history of smoking one to two packs of cigarettes daily. Which problem is the nurse most likely to find during the infant's assessment? sedation low birth weight hyperbilirubinemia hypocalcemia

low birth weight

On a client's first postpartum day, nursing assessment reveals vital signs within normal limits, a boggy uterus, and saturation of the perineal pad with lochia rubra. Which nursing intervention takes highest priority? administering oxytocin as ordered reassessing the client in 1 hour massaging the uterus gently notifying the physician or nurse-midw

massaging the uterus gently

After giving birth to a viable term male neonate vaginally under epidural anesthesia, a primiparous client asks the nurse, "Why are my baby's breasts so swollen?" The nurse responds to the client stating that slight breast engorgement in term neonates is due to which factor? epidural anesthesia genetic influences from both parents maternal hormonal influences maternal hyperthyroidism

maternal hormonal influences

As part of the respiratory assessment, a nurse observes the neonate's nares for patency and mucus. The information obtained from this assessment is important because nasal patency is required for adequate feeding. a deviated septum will interfere with breathing. problems with nasal patency may cause flaring. neonates are obligate nose breathers.

neonates are obligate nose breathers.

A nurse is performing a neurologic assessment on a neonate. Which assessment finding would be normal for a neonate? "sunset" eyes positive Babinski's reflex doll's eyes let-down reflex

positive Babinski's reflex

On the second postpartum day, a client tells the nurse she feels anxious and tearful. Which assessment finding is most consistent with the client's statement? poor coping skills postpartum psychosis postpartum "blues" postpartum depression

postpartum "blues

A client gave birth to a healthy full-term girl 2 hours ago by cesarean birth. When assessing this client which finding requires immediate nursing action? gush of vaginal blood when she stands up blood stain 2″ (5.1 cm) in diameter on the abdominal dressing tachycardia and hypotension complaints of abdominal pain

tachycardia and hypotension

The nurse is caring for a multigravida woman who is 1 day postpartum following a vaginal birth. Which finding indicates a need for further assessment? temperature of 100.8° F (38.2° C) pulse of 60 bpm white blood cell (WBC) count of 15,000 μL (15 X 109/L) hemoglobin 12.1 gm/dL (121 g/L)

temperature of 100.8° F (38.2° C)

A client is concerned that her 2-day-old, breast-feeding neonate isn't getting enough to eat. The nurse should teach the client that breast-feeding is effective if: the neonate latches onto the areola and swallows audibly. the neonate loses 10% to 15% of the birth weight within the first 2 days after birth. the neonate voids once or twice every 24 hours. the neonate breast-feeds four times in 24 hours.

the neonate latches onto the areola and swallows audibly.

The nurse is caring for a primigravida who gave birth to a viable neonate 2 hours ago under epidural anesthesia. The new mother has a midline episiotomy. Which finding by the nurse would warrant further assessment? two perineal pads soaked with blood within 30 minutes tenderness around the episiotomy site edema around the episiotomy site distended vaginal tissue

two perineal pads soaked with blood within 30 minutes

A nurse is conducting an assessment of a neonate born 3 hours ago. Which finding makes the nurse suspect a congenital hip dislocation? unlimited adduction of the affected leg unequal gluteal folds crepitus of the affected hip on movement lengthening of the limb on the affected side

unequal gluteal folds

When assessing an 18-year-old primipara who gave birth under epidural anesthesia 24 hours ago, the nurse determines that the fundus is firm but to the right of midline. Based on this finding, the nurse should further assess for which complication? urinary retention perineal hematoma paralytic ileus uterine inversion

urinary retention

A nurse is teaching a client how to perform perineal care to reduce the risk of puerperal infection. Which activity indicates that the client understands proper perineal care? changing perineal pads every 8 hours spraying water from peri bottle into the vagina using a peri bottle to clean the perineum after each voiding or bowel movement cleaning the perineum from back to front after a bowel movement

using a peri bottle to clean the perineum after each voiding or bowel movement

During the first hour after a precipitous birth, the nurse should monitor a multiparous client for signs and symptoms of which complication? urinary tract infection intrauterine infection uterine atony postpartum "blues"

uterine atony

A nurse is providing discharge teaching to a postpartum client. Which instruction is the priority to include in the teaching? "Sleep when the neonate sleeps to avoid exhaustion." "Don't worry. Women have been having babies for years without postpartum problems." "If you have excessive vaginal bleeding, massage your fundus and call the physician." "The neonate can sleep in the bed with you."

"If you have excessive vaginal bleeding, massage your fundus and call the physician."

The nurse is preparing to administer vitamin K intramuscularly to a term neonate of a primipara who has just given birth. After explaining the purpose of the drug to the mother, which statement by the mother indicates effective teaching? "Vitamin K will help my baby's blood to clot properly." "Vitamin K will help my baby breathe easier." "Vitamin K will prevent my baby from becoming jaundiced." "Vitamin K will prevent my baby from developing an infection."

"Vitamin K will help my baby's blood to clot properly."

A multiparous client who has a neonate diagnosed with hemolytic disease of the newborn asks the nurse why the neonate has developed this problem. Which response by the nurse would be most appropriate? "You are Rh-positive, and the baby is Rh-negative." "You are Rh-negative and the baby is Rh-positive." "You and the baby are both Rh-negative." "The baby and you are both Rh-positive."

"You are Rh-negative and the baby is Rh-positive."

A primiparous client who underwent a cesarean birth 30 minutes ago is to receive Rho(D) immune globulin. The nurse should administer the medication within which time frame after birth? 48 hours 12 hours 24 hours 72 hours

72 hours

The nurse makes a home visit to a 3-day-old full-term neonate who weighed 3,912 g (8 lb, 10 oz) at birth. Today the neonate, who is being bottle-fed, weighs 3,572 g (7 lb, 14 oz). Which instruction should the nurse give to the mother? Change to a higher-calorie formula to prevent further weight loss. Contact the health care provider (HCP). Continue feeding every 3 to 4 hours since the weight loss is normal. Switch to a soy-based formula because the current one seems inadequate.

Continue feeding every 3 to 4 hours since the weight loss is normal.

A woman who is Rh negative has given birth to an Rh-positive infant. The nurse explains to the client that she will receive Rho(D) immune globulin. The nurse determines that the client understands the purpose of the treatment when she reports that Rho(D) immune globulin has which action? preventing jaundice in her baby protecting her next baby if it is Rh negative preventing antibody formation in her blood preventing antigen formation in her baby's blood

Continue to monitor the client's vital signs.

While caring for a multiparous client 4 hours after vaginal birth of a term neonate, the nurse notes that the mother's temperature is 99.8°F (37.2°C), the pulse is 66 bpm, and the respirations are 18 breaths/min. Her fundus is firm, midline, and at the level of the umbilicus. What should the nurse do? Assess the client's lochia for large clots. Offer the mother an ice pack for her forehead. Notify the client's health care provider (HCP) about the findings. Continue to monitor the client's vital signs.

Continue to monitor the client's vital signs.

Which practice should a nurse recommend to a client who has had a cesarean birth? Side-rolling exercises Doing sit-ups 2 weeks after birth Frequent douching after she's discharged Coughing and deep-breathing exercises

Coughing and deep-breathing exercises

While assessing a 2-hour-old neonate, a nurse observes that the neonate has acrocyanosis. Which nursing action should the nurse perform at this time? Notify the physician that a cardiac consult is needed. Activate the code emergency response system. Take the neonate's temperature immediately according to hospital policy. Do nothing — acrocyanosis is normal in the neonate.

Do nothing — acrocyanosis is normal in the neonate.

The heart rate of a newly born neonate is regular at 142 bpm. What should the nurse do next? Document this as a normal neonatal finding. Notify the neonate's health care provider (HCP). Check for the presence of cyanosis. Assess the heart rate again in 3 hours.

Document this as a normal neonatal finding.

While a mother is feeding her full-term neonate 1 hour after birth, she asks the nurse, "What are these white dots in my baby's mouth? I tried to wash them out, but they're still there." After assessing the neonate's mouth, the nurse explains that these spots indicate which condition? thrush curds Koplik's spots precocious teeth Epstein's pearls

Epstein's pearls

During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she has been experiencing breast engorgement. To relieve engorgement, the nurse teaches the client to use which intervention before nursing her baby? Rub the nipples gently with lanolin cream. Offer the neonate a small amount of formula. Apply an ice cube to the nipples. Express a small amount of breast milk.

Express a small amount of breast milk.

Which instructions should the nurse give to the parents of a neonate diagnosed with hyperbilirubinemia who is receiving phototherapy? Keep the neonate's eyes completely covered. Check the rectal temperature every 8 hours. Offer feedings every 4 hours. Use a regular diaper on the neonate.

Keep the neonate's eyes completely covered.

A nurse caring for a 3-day-old neonate notices that he looks slightly jaundiced. Physiologic jaundice is caused by which characteristic? Poor clotting mechanism High hemoglobin (Hb) levels between 14 and 20 g/100 ml of blood Large, immature liver Persistent fetal circulation

Large, immature liver

While preparing to provide neonatal care instructions to a primiparous client who gave birth to a term neonate 24 hours ago, what should the nurse include in the client's teaching plan? Term neonates generally have few creases on the soles of their feet. Milia are white papules from plugged sebaceous ducts that disappear by age 2 to 4 weeks. Strawberry hemangiomas—deep, dark red discolorations—require laser therapy for removal. If erythema toxicum is present, it will be treated with antibiotic therapy.

Milia are white papules from plugged sebaceous ducts that disappear by age 2 to 4 weeks.

A primiparous client expresses concern, asking the nurse why her neonate's eyes are crossed. Which information would the nurse include when teaching the mother about neonatal strabismus? The neonate's eyes are unable to focus on light at this time. Congenital cataracts may be present. Neonates commonly lack eye muscle coordination. The neonate is able to fixate on distant objects immediately.

Neonates commonly lack eye muscle coordination.

A multiparous client at 24 hours postpartum is found to have a swelling and pain in her right leg. She demonstrates a positive Homan sign with discomfort. What should the nurse do next? Place the client in a semi-Fowler's position. Place a cold pack on the client's perineal area. Notify the client's health care provider (HCP) immediately. Ask the client to ambulate around the room.

Notify the client's health care provider (HCP) immediately.

Which measure included in the care plan for a client in the fourth stage of labor requires revision? Obtain an order for catheterization to protect the bladder from trauma. Check vital signs and fundal checks every 15 minutes. Perform perineal assessments for swelling and bleeding. Have the client spend time with the neonate to initiate breast-feeding.

Obtain an order for catheterization to protect the bladder from trauma.

When assessing a client who gave birth 24 hours ago, the post partum nurse expects to find the top of the client's fundus at which anatomic location? One fingerbreadth below the umbilicus One fingerbreadth above the umbilicus At the level of the umbilicus Below the symphysis pubis

One fingerbreadth below the umbilicus

During the initial assessment, the nurse notes that the neonate's hands and feet appear blue while the neonate's torso appears pale pink. What should the nurse do next? Place the infant skin to skin with the mother. Report the neonate's cyanosis to the primary care provider promptly. Ask the mother to massage the neonate's hands and feet. Keep the neonate in an isolation incubator for at least 2 hours.

Place the infant skin to skin with the mother.

The nurse plans care for a neonate to prevent neonatal heat loss immediately after birth. What action should the nurse take to conserve heat and help the infant maintain a stable temperature? Nestle the neonate against the crib wall. Place the infant skin to skin with the mother. Position the neonate lying in an open crib with a diaper on. Bathe the neonate with warm water.

Place the infant skin to skin with the mother.

When caring for a neonate, what is the most important step the nurse can take to prevent and control infection? Wearing gloves at all times Practicing meticulous hand washing Assessing frequently for signs of infection Using sterile technique for all caregiving

Practicing meticulous hand washing

The nurse notes that a neonate's Apgar score at 5 minutes was 9. The nurse interprets this as indicating which information about the neonate? Oxygen administration was necessary at birth. The neonate was in stable condition. Resuscitation was needed after birth. The neonate was cyanotic at birth.

The neonate was in stable condition.

Which finding requires further intervention in a mother who's breast-feeding? The neonate latches easily to the breast. The neonate's lips smack. The neonate makes swallowing noises when breast-feeding. The mother is comfortable positioning the neonate.

The neonate's lips smack.

A nurse is performing a neurologic assessment on a 1-day-old neonate in the nursery. Which findings indicate possible asphyxia in utero? Select all that apply. The neonate grasps the nurse's finger when she puts it in the palm of the neonate's hand. The neonate's toes do not fan out when soles of the feet are stroked. The neonate doesn't respond when the nurse claps her hands above him. The neonate turns toward the nurse's finger when she touches the neonate's cheek. The neonate displays weak, ineffective sucking. The neonate does stepping movements when held upright with sole of foot touching a surface.

The neonate's toes do not fan out when soles of the feet are stroked. The neonate doesn't respond when the nurse claps her hands above him. The neonate displays weak, ineffective sucking.

While caring for a neonate 2 days after birth, the nurse observes a swelling on the neonate's head that does not cross the cranial suture line. What should the nurse tell the client about the swelling? It will require several surgeries to repair. This is a normal symptom of a skull fracture that occurred during the birth. The swelling will resolve without treatment by 6 weeks of age. The area will remain swollen for at least 6 months before receding.

The swelling will resolve without treatment by 6 weeks of age.

According to the antenatal record, a newborn is 12 days post-mature. A nurse completes the initial assessment of the newborn and notes increased amounts of vernix. The mother asks why the nurse seems concerned about the presence of the vernix. Which of the following statements by the nurse is most appropriate? "The presence of vernix affects the newborn's immune system." "The vernix should be a thicker coating for a newborn." "The vernix indicates a different gestational age than expected." "The vernix is difficult and painful to remove from a newborn."

The vernix indicates a different gestational age than expected."

A primipara calls the birthing unit 3 days after a vaginal birth. She tells the nurse that she is bottle-feeding and her breasts are swollen and painful. Which instructions would be appropriate? Avoid wearing a bra to allow the engorgement to subside. Refrain from taking a shower with the water on the breasts. Use ice packs for 20 minutes every 3 to 4 hours. Wear a tight breast binder for the next 24 hours.

Use ice packs for 20 minutes every 3 to 4 hours.

After birth, a direct Coombs test is performed on the umbilical cord blood of a neonate with Rh-positive blood born to a mother with Rh-negative blood. The nurse explains to the client that this test is done to detect which information? initial bilirubin level appropriate dose of Rho(D) immune globulin presence of maternal antibodies degree of anemia in the neonate

presence of maternal antibodies

A client is at the end of her first postpartum day. The nurse is assessing the client's uterus. Which finding requires further evaluation? uterus in the midline position fundus one fingerbreadth below the umbilicus firm, round uterus fundus two fingerbreadths above the umbilicus

fundus two fingerbreadths above the umbilicus

In the fourth stage of labor, a full bladder increases the risk of what postpartum complication? disseminated intravascular coagulation (DIC) hemorrhage shock infection

hemorrhage

The nurse should be especially alert for what problem when caring for a term neonate, who weighed 10 lb (4,500 g) at birth, 1 hour after a vaginal birth? hypermagnesemia hyperbilirubinemia hypercalcemia hypoglycemia

hypoglycemia

A client at 4 weeks postpartum tells the nurse that she cannot cope any longer and is overwhelmed by her newborn. The baby has old formula on her clothes and under her neck. The mother does not remember when she last bathed the baby and states she does not want to care for the infant. The nurse should encourage the client and her husband to call their health care provider (HCP) because the mother should be evaluated further for which complication? poor bonding infant abuse postpartum blues postpartum depression

postpartum depression

The nurse makes a home visit to a primigravid client on the fourth postpartum day after birth of a term neonate. When the nurse enters the house, the nurse finds the client sitting in a chair, crying inconsolably, while the neonate is crying in another room. The client tells the nurse that she has not been sleeping well and has been hearing voices. The nurse determines that the client is most likely experiencing which condition? postpartum depression postpartum psychosis normal reactions to being a new mother the "baby blues.

postpartum psychosis

The nurse is caring for a client on her second postpartum day. The nurse should expect the client's lochia to be brown and scant. continuous with red clots. thin and white. red and moderate.

red and moderate.

A multiparous client, 28 hours after cesarean birth, who is breastfeeding has severe cramps or afterpains. The nurse explains that these are caused by which factor? healing of the abdominal incision after cesarean birth flatulence accumulation after a cesarean birth adverse effects of the medications administered after birth release of oxytocin during the breastfeeding session

release of oxytocin during the breastfeeding session

A woman who has given birth to a healthy neonate is being discharged. As part of discharge teaching, the nurse should instruct the client to observe vaginal discharge for postpartum hemorrhage and notify the health care provider (HCP) for which finding? lochia that lasts longer than 1 week bleeding that becomes lighter each day clots the size of grapes saturating a pad in less than an hour

saturating a pad in less than an hour