Chapter 27: Care of the Mother and Newborn - Study Guide

Refers to the process whereby an infant's behavior and characteristics call forth a corresponding set of maternal behaviors and characteristics.

Bonding

Normal value: relation of head to chest circumference

Head circumference is 1 inch larger than the chest

Motherhood is a(n) ________ skill.

Learned

Which assessment finding in a new infant should be reported to the health care provider for additional investigation?

Low-set ears

The nurse finds that the newborn is fed cow's milk. The primary health care provider prescribes stopping the feeding of cow's milk and to start feeding the newborn casein formula. What reason does the nurse expect the primary health care provider provide to the mother for this diet change?

The newborn may have nausea and skin rashes.

The home health nurse is assessing the mother's peripads 6 days after delivery. What is the expected findings?

Thin pinkish-brown drainage

What information would the postpartum nurse expect to get in a transfer report on a new patient who has delivered her baby and is being moved from the recovery area to the postpartum unit?

The postpartum nurse should be advised about the name of the primary care provider; gravidity and parity; age; anesthetic used; medications given; duration of labor and time of rupture of membranes; oxytocin induction or augmentation; type of birth and repair; blood type and Rh status; rubella immunity status; syphilis and hepatitis serology test results; intravenous (IV) infusion of any fluids; physiologic status since birth; description of fundus, lochia, bladder, and perineum; infant's sex and weight; time of birth; pediatrician; chosen method of feeding; any abnormalities noted; and assessment of initial parent-infant interaction.

Normal value: temperature

97.6 - 98.6 F

A postpartum patient reports numbness and tingling in the fingers. Which treatment strategy does the nurse expect to be most beneficial for the patient?

Administering diuretics intravenously (IV)

The nurse teaches care of the umbilical cord to a new mother. What instruction will the nurse provide?

Apply alcohol on the cord stump daily to keep it dry until it falls off

The mother reports to the nurse that the baby doesn't seem to be getting enough breast milk. What should the nurse do first?

Assess how the mother places the areola in the baby's mouth

The woman's temperature is slightly elevated 12 hours after delivery of the baby. What additional assessment would the nurse perform first?

Assess skin turgor and condition of mucous membranes

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?

Assess the abdomen and auscultate for bowel sounds

The nurse is teaching the patient about the signs and symptoms that should be reported to the health care provide. The patient is instructed to notify the health care provider if, after 5 days from the delivery date, the patient experiences?

Brest tenderness and redness

The woman is interested in returning to her pre-pregnant 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?

During breastfeeding, continue the diet recommended during pregnancy

A nurse observes a new mother turning away from her infant and sighing deeply. Which intervention would be most appropriate for the nurse?

Encourage the new mother to discuss her feelings by sitting next to her and stating, "Having a baby can be overwhelming."

The nurse observes a new mother turning away from her infant and sighing deeply. Which intervention would be most appropriate for the nurse?

Encourage the new mother to discuss her feelings by sitting next to her and stating, "Having a baby can be overwhelming."

The nurse notes on assessing the newborn that there is a small tuft of hair at the base of the spine. What is the clinical significance of this finding?

Hair tufts indicate possible abnormalities of spinal column developement

Gastrointestinal changes in mother after birth

Hemorrhoids, constipation

A new mother reports feeling weak, light-headed, and being sick to her stomach. The LPN/LVN also notes that the patient's perineal pad is soaked since she last checked it 15 minutes ago. The patient's skin is cool and clammy. The pulse is 110 bpm and the blood pressure is 80/60. What complication do these symptoms indicate?

Hypovolemic shock

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?

Lochia rubra, moderate

The student nurse observes that the patient holds the breast away from the infant's nostrils while feeding the infant. What does the student nurse understand from this action?

The patient is trying to promote proper respiration in the infant.

Integumentary changes in mother after birth

reduction of hyper-pigmentation, increased elasticity

Which actions by the nursing mother will support milk production and promote infant comfort? (select all that apply)

- Drink 8 to 10 glasses of fluids daily - Avoid spicy foods, chocolate, and onions - Continue taking prenatal vitamins and minerals until they are gone

The primary health care provider instructs the nurse to administer 1 mg vitamin K injection (Aquamephyton) intramuscularly to a neonate immediately after birth. Which factors does the nurse primarily monitor in the neonate after administering the medication? (select all that apply)

- Symptoms of kernicterus - Symptoms of hyperbilirubinemia - Symptoms of hemolytic anemia

A nurse is providing postpartum teaching to a patient about self-care after discharge. Which statement if made by the patient would require the nurse to reinforce teaching?

"I can't wait to soak in my Jacuzzi tub."

A postpartum client is getting ready for discharge. The nurse suspects that the client needs further teaching related to breastfeeding when she makes which statement?

"I don't need birth control because I will be breastfeeding."

Newborns' and Mothers' Health Protection Act of 1996 requires all health plans to allow the new mother and the newborn to remain in the hospital for a minimum of _____ hours after a normal vaginal birth and ______ hours after a cesarean birth.

- 48 - 96

Which physical signs and symptoms might the postpartum patient experience following delivery? (select all that apply)

- A normal bowel movement within 2 to 3 days - Increased diaphoresis, most commonly at night - Increased urination beginning 4 to 6 hours after delivery

Normal variation(s) in the physical characteristics of a newborn that the parents should not be alarmed in seeing is/are? (select all that apply)

- Acrocyanosis in an infant that is 5 days old - The harlequin sing in a 2-day-old infant - Epstein's pearls on the hard palate of a 2-week-old infant - Lacy mottling on pale skin immediately at birth

A postpartum patient is experiencing weakness and says that she is sick to her stomach. When the nurse performs an assessment, the patient has a pulse rate of 120 and a 60/48 blood pressure, and when touched the skin is cool and clammy. Which interventions should the nurse institute? (select all that apply)

- Massage the fundus - Elevate legs 30 degrees - Give oxygen if prescribed - Maintain intravenous (IV) fluids

The student nurse is caring for a patient after delivery. The patient states, "I feel very weak and, sometimes, I see stars around me." Which interventions should the nurse in charge advise the student nurse to do in order to provide effective care to the patient? (select all that apply)

- Monitor the patient's vital signs. - Gently massage the patient's uterus. - Notify to the primary healthcare provider.

The nurse is preparing a list of self-care instructions for a postpartum client who has been diagnosed with mastitis. Which instructions should be included on the list? (Select all that apply)

- Rest during the acute phase - Wear a supportive, non-underwire bra - Maintain a fluid intake of at least 3000 mL - Continue to breastfeed if the breasts are not too sore

Normal value: pulse

110-160 beats/minute

Normal value: respirations

30-60 respirations/minute

A patient with hyperglycemia had a preterm delivery. What intervention would the nurse most probably plan to prevent complications in the newborn?

Administer glucose solution to the newborn one hour after birth.

A nurse teaches care of the umbilical cord to a new mother. What instruction will the nurse provide?

Apply alcohol on the cord stump daily to keep it dry until it falls off

The nurse sees that the postpartum patient has an elevation in platelet count. Based on this observation, which action will be nurse perform?

Encourage the patient to get out of bed and walk around

The nurse identifies that the mother requires additional teaching on the care of the infant's umbilicus if she?

Gives a tub bath in the first 3 days after delivery

The decrease in size of the uterus is called ______?

Involution

Which nursing observation of the newborn's bowel function should be reported to the health care provider?

No stool is passed 24 hours after birth

Endocrine changes in mother after birth

Reduction in estrogen and progesterone levels

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?

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

Care of the circumcision includes?

Applying the diaper loosely

The nurse notes that the patient is profusely diaphoretic during the first night after delivery. Based on the nurse's knowledge of what is expected for the healthy mother in the immediate postpartum period, which action is the nurse most likely to take?

Assist the patient to change clothes and explain that diaphoresis is normal

Postpartum fatigue and ________ are common as a result of hormonal and physiologic changes.

Depression

When is infant abduction most likely to occur?

During visiting hours

The nurse can help a father in his transition to parenthood with what action?

Pointing out that the infant turned to his voice

What is the role of prolactin during lactation?

Responsible for stimulating milk production in the mammary alveolar cells

What are the benefits of breastfeeding?

- Anti-infective properties - Nutrition - Growth and development - Allergy - Maternal benefits

What are some nursing interventions for an episiotomy, a laceration, and hemorrhoids?

- Cleansing - Ice pack - Squeeze bottle - Sitz bath - Dry heat - Topical applications

A baby has a Gomco circumcision. What instruction should the nurse give his parents for care of the circumcised penis?

Cover the glans with a petroleum gauze dressing

The patient received an epidural block. In the early recovery stage, what would be considered a normal finding?

Decreased sensation in both legs

What is lochia serosa?

Discharge thins and becomes pink to brown as the placental site heals

The tissue of light-skinned women, especially those with reddish hair, is not as readily _______ as that of darker-skinned women, and healing maybe less efficient.

Distensible

What is lochia alba?

Drainage is slightly yellow to white after the seventh day and continues for another 10-12 days

Refers to the face-to-face position in which a parent's and infant's faces are approximately 20 cm apart and on the same plane or level.

En face

After delivery, which patient has the greatest risk for life-threatening postpartum hemorrhage?

Has a retroperitoneal hematoma due to rupture of a cesarean scare

Urinary changes in mother after birth

Initial diuresis, possible retention

The nurse is assisting which caring for a postpartum client who is experiencing uterine hemorrhage. When planning to meet the psychosocial needs of the client, the nurse should plan which action?

Keeping the client and her family members informed of her progress

The mother has lost a large volume of blood and appears to be in hypovolemic shock following the delivery. The nurse implements an appropriate action by?

Providing oxygen by face-mask at 8-10 L/min

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?

The baby has 6 to 10 wet diapers per day

What is lochia?

The bloody discharge after delivery once the uterine lining is shed; consists of blood, tissue, and mucus

After episiotomy and the delivery of a newborn, the nurse performs a perineal check on the mother. The nurse notes a trickle of bright red blood coming from the perineum. The nurse checks the fundus and notes that it is firm. Which determination should the nurse make?

The bright red bleeding is abnormal and should be reported

How should the nurse provide care for the umbilical cord?

The cord clamp must be securely fastened with no skin caught in it. It may be treated with a bactericidal substance, such as triple-dye solution, antibiotic ointment, or alcohol, three times a day or allowed to dry naturally. When soiled, the cord should be cleaned with water The diaper is folded below the cord to keep the cord dry and free from contamination with urine. Remove the cord clamp about 24 hours after birth if the end of the cord is dry.

On reviewing the case reports, the nurse finds that the infant passes watery and green stools. The nurse learns that the infant had passed the transition stools on the second day after birth. What does the nurse infer from these findings?

The infant has gastrointestinal irritation.

In evaluating maternal adjustment, which behavior leads the nurse to believe that the patient is still in the taking-in phase?

The majority of the mother's time is spent talking about her delivery experience

The newborn infant weights 6.6 pounds. How much fluid does this healthy baby need every day?

420-480 mL/day

An Rh-negative patient gives birth to an Rh-positive baby. What essential intervention should the nurse perform?

Administer RhoGAM as prescribed

Newborns are not able to synthesize vitamin K in the colon until they have adequate intestinal flora. Which action would the nurse take?

Administer an injection of vitamin K (AquaMEPHYTON) as ordered

An appropriate technique to teach the new mother about the baby's bath is?

Having the bathwater at 100 F (37.7 C)

The newborn infant has a blood glucose level of 40 mg/dL. The nurse prepares for which intervention?

Oral feeding of sterile glucose water

Haitian women may request to take the ________ home to bury or burn.

Placenta

The _______ lasts about 3-6 weeks, from the time the woman delivers the placenta until the reproductive organs return to the non-pregnant size and position.

Puerperium

The nurse is caring for a newborn baby. The nurse finds the baby has developed jaundice 24 hours after birth. What is the most probable reason for this condition in the newborn?

The newborn's liver is too immature to remove bilirubin from the blood.

Normal value: head circumference

13-14 inches

An infant requires 160 mL of intravenous (IV) rehydration fluids per kilogram daily. How many milliliters will an infant weighing 8 pounds require in a 24-hour period?

581 mL

Normal value: blood pressure

60-80/40-50 mmHg

The mother reports a mild cramping during the postpartum period. The nurse anticipates that the health care provider will write a PRN order for which medication?

Acetaminophen

A nursery nurse has instructed a mother on care of the penis after circumcision. Which statement indicates the mother does not fully understand care of the penis after a circumcision?

"I must apply the diaper extra snugly to control the bleeding."

The nurse teaches the mother of a newborn about the steps to be taken for the feeding process of the newborn. Which statement made by the mother indicates effective learning?

"I should give 15 mL of water to my baby before giving formula."

The patient has opted to bottle-feed her newborn. The nurse is confident that the patient has understood discharge teaching related to breast engorgement when the patient states?

"If I experience engorgement, I should use ice to try to get some relief."

Discharge instructions regarding breastfeeding and home care are given to a new mother. After the nurse completes the instructions, the patient is given an opportunity to ask questions. Which question if asked by the patient would warrant additional teaching?

"Should I wait a week before beginning my diet?"

The nurse is trying to teach a 15-year-old mother how to swaddle the baby, but the young mother seems more interested in how her hair and makeup look. She states, "My boyfriend is coming in a little while." How should the nurse respond?

"You look very pretty. He will be delighted to see you and the baby."

What are the most appropriate nursing concerns for a breastfeeding mother? (select all that apply)

- Anxiety related to lactation expectations - Decreased caloric intake because of lactation needs - Potential for infection related to dry, cracked nipples

The nurse is caring for a postpartum patient. Which physiologic adaptations does the nurse expect to occur in the patient in this phase? (select all that apply)

- Bruising of the perineum - Sloughing of the uterine lining - Rapid decline of cardiac output

The nurse is caring for a postpartum patient who has lacerations on the anterior rectal wall. Which nursing intervention would be most suitable for the patient? (select all that apply)

- Instructing the patient to drink a lot of fluids - Administering stool softeners to the patient - Assessing the fecal continence of the patient

The nurse is caring for a postpartum patient who is administered oxytocin (Pitocin). Which symptoms should the nurse monitor for in the patient to ensure safe administration of the medication? (select all that apply)

- Water intoxication - Irregular heartbeat - Decreased blood pressure

Which treatment related to bowel function would the nurse question for a woman with a fourth-degree laceration of the perineum?

Administer enema for constipation as needed

The nurse suspects that the client has a pulmonary embolism. Which is the most important nursing action?

Administer oxygen by face mask, as prescribed

The nurse is assigned to care for the client after a cesarean section. To prevent thrombophlebitis, the nurse should encourage the woman to take which priority action?

Ambulate frequently

A recovery nurse is caring for a patient who delivered via a cesarean 8 hours ago. What data if read on the nursing documentation would indicate a potential complication may be developing?

Apical pulse is 25 beats above predelivery baseline.

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?

Applying ice to the breasts for comfort

The nurse is caring for an infant who has undergone circumcision and finds that the infant has severe bleeding from the site. Which intervention does the nurse expect to be most beneficial for the infant?

Arrange for the ligation of the bleeding blood vessel

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?

Ask the mother to hold the baby while vital signs are obtained

The nurse is performing a routine postpartum assessment. Which action is indicated before the fundal height is measured?

Ask the patient to empty her bladder

An LPN/LVN is assessing a postpartum patient when the patient reports pain in her right calf. The LPN/LVN notes the area is reddened and edematous. What is the LPN/LVN's next intervention?

Assess for a positive or negative Homan sign

The LPN/LVN is assessing a postpartum patient when the patient reports pain in her right calf. The LPN/LVN notes the area is reddened and edematous. What is the LPN/LVN's next intervention?

Assess for a positive or negative Homan sign

The nurse notices that the grandmother seems to be dominating the care of her own daughter and the new infant to the point of excluding the new father. What should the nurse do?

Assess the father's feelings about his role and his knowledge of child care

When performing a postpartum assessment, what should the nurse do?

Assist the patient into a supine position with her arms above her head and her legs extended for the examination of her abdomen

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?

Assist the patient to slowly sit and dangle legs while seated

What is lochia rubra?

Bright red drainage during the first day or two after delivery; consisting mostly of blood

A patient who has had a routine vaginal delivery has a urinary output of 100 mL, 150 mL, and 275 mL recorded for three voids. What is the best action for the nurse to take?

Catheterize the patient if ordered

The unlicensed assistive personnel (UAP) tells the nurse that there was a gush of brownish vaginal drainage when the patient got out of bed and stood up. What should the nurse do first?

Check on the patient and assess for pain, dizziness, or continued vaginal flow

The postpartum patient complains of a persistent headache. Which action would the nurse perform first?

Check the blood pressure and compare it to baseline measurements

The nurse notes that the 4-hour postpartum client has cool, clammy skin and that she is restless and excessively thirsty. The nurse immediately notifies the registered nurse and then performs which action?

Checks the vital signs

A patient has requested medication for gas pains. Simethicone (Mylicon) has been prescribed. How should the nurse instruct the patient to take the medication?

Chew the pill thoroughly before swallowing

While caring for a newborn, the nurse finds asymmetric gluteal folds in the newborn. Which complication does the nurse expect to find in the newborn?

Congenital hip dysplasia

Cardiovascular changes in mother after birth

Decrease in blood volume and cardiac output

Is a term applied to a parent's absorption, preoccupation, and interest in his or her infant; the term typically is used to describe the father's intense involvement with his newborn.

Engrossment

The father's behavior when introduced to his new baby is typically an intense fascination. What is this behavior considered?

Engrossment

The nurse helps the breastfeeding 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?

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

During a postpartum check, the nurse assesses the new mother's uterus and notes it to be boggy. What is the nurse's first intervention?

Gently massage the fundus to increase contractility

The nurse palpates the uterus of a postpartum patient for involution and observes that the uterine fundus is soft and distended. What does the nurse expect the primary health care provider to prescribe to the patient?

Methylergonovine maleate (Methergine)

The nurse is caring for a postpartum client. At 4 hours postpartum, the client's temperature is 102 F (38.9 C). Which is the appropriate nursing action?

Notify the registered nurse, who will then contact the health care provider (HCP)

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?

Palpate the woman's fundus

The nurse is assessing the extremities of a newborn, and places a thumb at the base of the newborn's toes, observing that the newborn curls its toes downward. Which reflex does the nurse understand is demonstrated in the newborn?

Planter grasp reflex

The nurse is assisting with planning care for a postpartum woman who has small vulvar hematomas. To assist with reducing the swelling, the nurse should perform which action?

Prepare an ice pack for application to the area

The client received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum, the client's systolic blood pressure (BP) dropped 20 points,, the diastolic BP dropped 10 points, and her pulse is 120 beats per minute. The client is very anxious and restless. The nurse is told that the client has a vulvar hematoma. Based on this diagnosis, the nurse should plan which action?

Preparing the client for surgery

The nurse is teaching a postpartum patient about umbilical cord care. The nurse advises the patient to fold the diaper down such that the plastic side is facing outside. What would be the possible reason behind giving this suggestion?

Preventing moisture retention in the umbilicus

In teaching the new mother about breastfeeding, the nurse informs her to?

Put as much of the areolar tissue into the baby's mouth as possible

The vital signs of a newborn baby girl are as follows: T 97.9°, P 140, R 34 with brief periods of apnea, and BP 80/40 with an increase in systolic pressure when crying. What is the nurse's next intervention?

Realize these vital signs are normal for a newborn and document the data on the flow sheet

Is the phase of maternal postpartum adjustment characterized by a woman's need to review her labor and birth experiences with the nurse who cared for her while she was in labor. Other behaviors exhibited include reliance on others to help her meet needs, excitement, and talkativeness.

Taking-In

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 respiration of 42 breaths/min with adequate chest movement, a heart rate of 145 bpm, 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?

Temperature will stabilize at 36.5° to 37° C

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?

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

What are some apparent warning signs of possible difficulties in parent-child relationships immediately following delivery?

The mother may appear angry or indifferent, turns away from the baby, concentrates on her own pain, or makes hostile comments

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?

The mother seldom makes eye contact with her son

A lactation consultant is monitoring a new mother breastfeeding for the first time. What behavior if witnessed would call for immediate corrective action?

The mother swiftly removes the breast from the infant's mouth.

How do bowel elimination differ among newborns?

The newborn's initial stools are odorless, black-green, and sticky. Breastfed babies tend to pass stool frequently, sometimes with every feeding. The stool is pale yellow and sweet smelling. Small curds may be observed. Babies who are bottle fed tend to have fewer stools, usually two or three per day after the first 2 weeks. These are bright yellow and pasty in consistency; the odor may be slightly stronger than that of breastfed babies.

The nurse is caring for a postpartum patient who has significant bleeding. The primary health care provider prescribed an intravenous infusion of lactated Ringer's solution. What could be the possible reason for prescribing this infusion?

The patient feels weak and has frequent vomiting.

The nurse is reviewing the lab reports of a postpartum patient and the newborn, and expects the primary health care provider to prescribe Rhogam to the patient. Which finding enabled the nurse to reach this conclusion?

The patient is Rh negative and the newborn is Rh positive.

A labor and delivery nurse explains perineal care to a patient after delivery. Which action if performed by the patient indicates that perineal care is not clear to the patient?

The patient vigorously wipes the perineal area after urinating.

During the later postpartum stage, what are the activity and exercise restrictions?

The physician indicates when postpartum exercises are suitable for the new mother, whether she delivered vaginally or via cesarean. The woman should begin gradually and avoid vigorous exercise until after the examination at 6 weeks, when the physician releases her to do so. Teach her isometric exercises that help toning without causing undue exertion.

The licensed practical nurse is assessing a postpartum patient 10 weeks after delivery. During palpation, the nurse finds that the patient's uterus is involuted. Which finding enabled the nurse to reach this conclusion?

The uterine fundus is no longer palpable.

A Vietnamese mother delivered a full-term infant several hours ago. The mother changes the diaper and provides basic care but fails to cuddle, kiss, or converse with the infant. Based on the interaction between the mother and the infant, what can the nurse infer?

This behavior is normal for a mother of this culture.

Why is it critical for the fundus of the uterus to remain firm and midline during the recovery stage?

This is critical because severe bleeding may result if the uterus does not tightly constrict the placental site

A 3-hour-old infant is beginning to show a yellow discoloration to the skin. What should the nurse understand about the jaundice occurring in this infant?

This jaundice is likely related to maternal-fetal blood incompatibility.

The nurse finds that the glucose level in a neonate is 45 mg/dL and advises the parents to avoid giving glucose supplements to the neonate before breastfeeding. Why does the nurse give this advice to the parents?

To ensure that the neonate takes interest in breastfeeding

The nurse is caring for a patient who had a caesarean delivery and was administered general anesthesia. The nurse suggests the patient walk at frequent intervals and avoid continuous bedrest. What could be the probable reason for this suggestion?

To help promote bowel function

While caring for a lactating patient, the nurse suggests that the patient place the infant on her shoulder after feeding. What is the reason behind this suggestion?

To promote burping in the infant

What are the nutritional and metabolic issues of a woman during the later postpartum stage?

Women who are not breastfeeding should continue to eat a well-balanced diet that follows MyPlate suggestions. Women who are breastfeeding generally continue the diet recommended during pregnancy because the body needs extra calories, vitamins, and minerals for lactation. The breastfeeding mother should maintain the increased caloric intake of 300 to 500 kcal/day as part of a well-balanced diet and should maintain a daily fluid intake of 2 to 3 L.

In some cultures, including Chinese, Mexican, Korean, and Southeast Asian, there are certain postpartum rituals for mother and baby. These may include _______, _______, and _______ restrictions designed to restore the hot-cold (yin-yang) balance.

- bathing - activity - dietary

After delivery the nurse checks the height of the uterine fundus. Which position of the fundus should the nurse expect to note?

At the level of the umbilicus

Parent-child ________ is the process by which parent and child come to love and accept each other.

Attachment (bonding)

When teaching parents how to bathe their baby, which point should the nurse stress?

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

The nurse is discussing sexuality with the new mother. What information should the nurse provide?

Avoid sexual activity until after the first postpartum office visit

A mother is breastfeeding her newborn baby and experiences breast engorgement. The nurse should encourage the mother to do which to provide relief of the engorgement?

Massage the breasts before feeding to stimulate let-down

Which actions by the nursing mother will support milk production and promote infant comfort? (Select all that apply.)

- Drink 8 to 10 glasses of fluids daily - Continue her prenatal vitamins and minerals until they are gone - Avoid spicy foods, chocolate, and onions

The nurse is assigned to care for the client during the postpartum period. The client asks the nurse what the term involution means. Which description should the nurse give to the client?

The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1 cm/day

When providing education to parents about care of the umbilical cord, what information should be included? (Select all that apply.)

- Cleaning the cord with an alcohol swab - Keeping the diaper folded below the cord

A new graduate has been assigned to the newborn transition nursery at a large metropolitan facility. Which medication(s) should the new graduate anticipate administering to all babies admitted to the nursery? (select all that apply)

- Erythromycin drops - Vitamin K (Aquamephyton)

A nurse is discharging a newborn infant. The parents should be instructed to call the primary health care provider if which symptoms are experienced? (select all that apply)

- Fever - Diarrhea - Vomiting

A recently delivered mother has a nonimmune status to the rubella vaccine. The nurse administers the vaccine shortly before discharge. What essential information should the nurse include as part of the teaching process?

Avoid conceiving for at least 3 months.

While caring for a postpartum patient, the student nurse finds that the licensed practical nurse placed an ice pack on the perineum of the patient four hours after delivery. What is the reason for this nursing intervention?

To provide pain relief

The primary health care provider instructs the nurse to administer an intramuscular injection of vitamin K (Aquamephyton) to a newborn immediately after birth. What is the reason behind this intervention?

To reduce the risk of bleeding

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?

Uterine hemorrhage and urinary tract infections

The nurse is caring for a postpartum client with a diagnosis of thrombophlebitis. The client suddenly complains of chest pain and dyspnea. The nurse should initially check which item?

Vital signs

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.)

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

What are the most appropriate nursing diagnoses for a breastfeeding mother? (Select all that apply.)

- Imbalanced nutrition: less than body requirements related to the demands during lactation - Anxiety related to lactation expectations - Potential for infection related to dry, cracked nipples

Which physical signs and symptoms might the postpartum patient experience following delivery? (Select all that apply.)

- Increased urination beginning 4 to 6 hours after delivery - Increased diaphoresis, most commonly at night - A normal bowel movement within 2 to 3 days

The nurse is assessing a newborn infant who was just born at 30 weeks gestation. Which findings would be considered normal? (select all that apply)

- Vernix caseosa - Lanugo - Good skin turgor - Good tissue elasticity

The nurse is teaching breast care for the lactating woman. What information should be included? (Select all that apply.)

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

The vital signs of a newborn baby girl are: T-97.9, P-140, R-34 with brief periods of apnea, and B/P-80/40 with an increase in systolic pressure when crying. What is the nurse's next intervention?

Realize these vital signs are normal for a newborn and document the data on the flow sheet

The nurse palpates the fundus and checks the character of the lochia of a postpartum client who is in the fourth stage of labor. Which lochia characteristic should the nurse expect to note?

Red