exam 2

The serosa stage of lochia usually occurs between day __________ and __________ and the lochia is a __________ or __________ color, and the amount is normally __________.

ANS: 1 - 4; 10; pink; brown; scant Lochia rubra (first stage) occurs during the first 3 days postpartum. Lochia rubra is bright red blood and is moderate to scant. Lochia alba (third stage) begins around the tenth day. The lochia is yellow to white in appearance and is scant in amount.

The postpartum period is the first __________ weeks following childbirth.

ANS: 6 Postpartum is the 6-week period of time following childbirth. It is a time of rapid physiological changes within the woman's body as it returns to a prepregnant state.

12. Maddy, a G3 P1 woman, gave birth 12 hours ago to a 9 lb. 13 oz. daughter. She experiences severe cramps with breastfeeding. The perinatal nurse best describes this condition as: a. Afterpains b. Uterine hypertonia c. Bladder hypertonia d. Rectus abdominis diastasis

ANS: A Afterpains (afterbirth pains) are intermittent uterine contractions that occur during the process of involution. Afterpains are more pronounced in patients with decreased uterine tone due to overdistension, which is associated with multiparity and macrosomia. Patients often describe the sensation as a discomfort similar to menstrual cramps.

10. The nurse is working with a 36-year-old, married client, G6 P6, who smokes. The woman states, "I don't expect to have any more kids, but I hate the thought of being sterile." Which of the following contraceptive methods would be best for the nurse to recommend to this client? a. Intrauterine device b. Contraceptive patch c. Bilateral tubal ligation d. Birth control pills

ANS: A An intrauterine device (IUD) is an excellent contraceptive method for women who have had at least one delivery, are in a monogamous relationship, and wish to have long-term contraception. The contraceptive patch is not recommended for women over 35 or for women who smoke. A bilateral tubal ligation is a sterilization procedure. Birth control pills are not recommended for women over 35 or for women who smoke.

9. The nurse is providing discharge counseling to a woman who is breastfeeding her baby. The nurse advises the woman that if she experiences unilateral breast inflammation, she should do which of the following? a. Apply warm soaks to the reddened area. b. Consume an herbal galactagogue. c. Bottle feed the baby during the next day. d. Take expressed breast milk to the laboratory for analysis.

ANS: A The client may be developing mastitis. She should apply warm soaks to the area. There is no need for a galactagogue. It is essential that the client continue to breastfeed. If she were to stop feeding, she could develop a breast abscess. Unless ordered by the physician, the milk need not be cultured.

14. A 37-year-old gravid 8 para 7 woman was admitted to the postpartum unit at 2 hours postbirth. On admission to the unit, her fundus was U/U, midline, and firm, and her lochia was moderate rubra. An hour later, her fundus is midline and boggy, and the lochia is heavy with small clots. Based on this assessment data, the first nursing action is: a. Massage the fundus of the uterus. b. Assist the woman to the bathroom and reassess the fundus. c. Notify the physician or midwife. d. Start IV oxytocin therapy as per standing orders.

ANS: A a. Correct. Based on the assessment data that the uterus is midline and boggy, the woman is experiencing uterine atony. b. Assisting the woman to the bathroom would be a nursing action if the uterus was not midline. c. Oxytocin would be given and the primary health provider would be notified if the uterus did not respond to uterine massage. d. Oxytocin would be given and the primary health provider would be notified if the uterus did not respond to uterine massage.

1. A postpartum woman has been diagnosed with postpartum psychosis. Which of the following actions should the nurse perform? a. Supervise all infant care. b. Maintain client on strict bed rest. c. Restrict visitation to her partner. d. Carefully monitor toileting

ANS: A a. It is essential that a client diagnosed with postpartum (PP) psychosis not be left alone with her infant. b. There is no need for a client with PP psychosis to be on strict bed rest. c. Visitation is not usually restricted to the woman's partner. d. There is no need to monitor the client's toileting.

13. Which of the following is an indication for the administration of methylergonovine? a. Boggy uterus that does not respond to massage and oxytocin therapy b. Woman with a large hematoma c. Woman with a deep vein thrombosis d. Woman with severe postpartum depression

ANS: A a. Methylergonovine (methergine) is ordered for PPH due to uterine atony or subinvolution. It is used when massage and oxytocin therapy have failed to contract the uterus. b. Hematoma occurs when blood collects within the connective tissues of the vagina or perineal areas related to a vessel that ruptured and continues to bleed. Methylergonovine stimulates contraction of the smooth muscle of the uterus and would not have an effect on the vaginal or perineal areas. c. Heparin is usually prescribed for treatment of thrombosis. d. Methylergonovine is prescribed for treatment of uterine atony.

7. A woman is 2 days postpartum from a normal vaginal delivery over an intact perineum of a 3000-gram baby. Where would the nurse expect to palpate the client's fundus? a. At the umbilicus b. 2 cm below the umbilicus c. 2 cm above the symphysis d. At the symphysis

ANS: B Expected location for 6 to 12 hours postpartum. The firm fundus should be 2 cm below the umbilicus. This is an abnormal finding and may be related to subinvolution of the uterus. Expected location for 6 days postpartum.

3. During a postpartum assessment, the nurse notes that the uterus is midline and boggy. The immediate nursing action is:a. To notify the patient's midwife or physician b. Massage the fundus until firm and reevaluate within 30 minutes c. Give Syntocinon as per orders d. Assist the patient to the bathroom and ask her to void

ANS: B If the uterus does not respond to massage, then the nurse would give Syntocinon and notify the primary health provider. The first nursing action for a boggy uterus is to massage the fundus. If the uterus does not respond to massage, then the nurse would give Syntocinon and notify the primary health provider. You would assist the woman to the bathroom if the uterus is boggy and displaced to the side.

11. The perinatal nurse demonstrates for the student nurse the correct technique of postpartum uterine palpation. Support for the lower uterine segment is critical, as without it, there is an increased risk of: a. Uterine edema b. Uterine inversion c. Incorrect measurement d. Intensifying the patient's level of pain

ANS: B Placing the hand over the base of the uterus does not cause uterine edema. The uterine fundus is palpated by placing one hand on the base of the uterus immediately above the symphysis pubis and the other hand at the level of the umbilicus. The nurse presses inward and downward with the hand positioned on the umbilicus until the fundus is located. It should feel like a firm, globular mass located at or slightly above the umbilicus during the first hour after birth. The uterus should never be palpated without supporting the lower uterine segment. Failure to do so may result in uterine inversion and hemorrhage. Measurement is the same with or without the hand supporting the lower uterine segment. Not supporting the lower uterine segment has no effect on the level of pain felt by the patient.

1. A 25 year-old woman gave birth to her second child 6 hours ago. She informs the nurse that she is bleeding more than with her previous birth experience. The initial nursing action is to: a. Explain that this is normal for second-time moms. b. Assess the location and firmness of the fundus. c. Change her pad and return in 1 hour and reassess. d. Give her 10 units of oxytocin as per standing order.

ANS: B The nurse should not inform the patient that this is normal until she has assessed for the degree and potential cause of bleeding. It is important to first assess for uterine atony or displaced uterus from full bladder. If the uterus is firm and midline, then the nurse should change the pad and return within 30 minutes to assess the amount of lochia. The nurse would give oxytocin if the uterus is boggy and does not respond to uterine massage.

16. During change of shift report, the nurse hears the following information on a newly delivered client: 27 years old, married, G4 P3, 8 hours postspontaneous vaginal delivery over 3º laceration, vitals—110/70, 98.6ºF, 82, 18, fundus firm at umbilicus, moderate lochia, ambulated to bathroom to void three times for a total of 900 mL, breastfeeding every 2 hours. Which of the following nursing diagnoses should the nurse include in this client's nursing care plan? a. Fluid volume deficit b. Impaired skin integrity c. Impaired urinary elimination d. Ineffective breastfeeding

ANS: B There is nothing in the scenario that indicates that this client has had a significant blood loss. The client has a 3º laceration. A nursing diagnosis of impaired skin integrity is appropriate. The client is voiding well. There is no indication of impaired urinary elimination. The client is feeding q 2 h. There is no indication of impaired breastfeeding.

2. Which of the following sites is priority for the nurse to assess when caring for a breastfeeding client, G8 P5, who is 1 hour postdelivery? a. Nipples b. Fundus c. Lungs d. Rectum

ANS: B a. Her nipples should be assessed, but this is not the priority assessment. b. This client is a grand multipara. She is high risk for uterine atony and postpartum hemorrhage. The nurse should monitor her fundus very carefully. c. Her lungs should be assessed bilaterally, but this is not the priority assessment. d. Her rectum should be assessed for hemorrhoids, but this is not the priority assessment.

Mastitis is an inflammation of the __________.

ANS: Breast Mastitis is an inflammation or infection of the breast. This can occur when bacteria enter the breast through cracks around the nipple area

2. Which of these medications is commonly used to control postpartum bleeding related to uterine atony? a. Magnesium sulfate b. Phytonadione c. Oxytocin d. Warfarin

ANS: C Magnesium sulfate is commonly used for PIH and preterm labor. It is a smooth muscle relaxant and can cause the uterus to relax. Phytonadione (vitamin K) is important for clotting but will not cause the uterus to contract. Oxytocin is commonly used to control postpartum bleeding related to uterine atony. Warfarin is an anticoagulant and will increase the risk of hemorrhage.

13. A 35-year-old G1 P0 postpartum woman is Rh0(D)-negative and needs Rh0(D) immune globulin to be administered. The most appropriate dose that the perinatal nurse would expect to be ordered would be: a. 120 ug b. 250 ug c. 300 ug d. 350 ug

ANS: C Nonsensitized women who are Rh0(D)-negative and have given birth to an Rh(D)-positive infant should receive 300 ug of Rh0(D) immune globulin (RhoGAM) within 72 hours after giving birth. RhoGAM should be given whether or not the mother received RhoGAM during the antepartum period. In some situations, depending on the extent of hemorrhage and exchange of maternal-fetal blood, a larger dose of RhoGAM may be indicated.

6. A nurse is performing a postpartum assessment 30 minutes after a vaginal delivery. Which of the following actions indicates that the nurse is performing the assessment correctly? a. The nurse measures the fundal height in relation to the symphysis pubis. b. The nurse monitors the client's central venous pressure. c. The nurse assesses the client's perineum for edema and ecchymoses. d. The nurse performs a sterile vaginal speculum exam.

ANS: C The fundal height should be measured in relation to the umbilicus. The central venous pressure is not monitored during postpartum assessments. The nurse should assess the perineum for signs of edema and ecchymoses. If a speculum exam were needed, a physician or midwife would perform the procedure. Speculum exams are rarely needed postpartum.

8. Which of the following clients is most likely to complain of afterbirth pains during her postpartum period? a. G1 P0, diagnosed with preeclampsia b. G2 P0, group B streptococci in the vagina c. G3 P2, gave birth to a 4100-gram baby d. G4 P1, diagnosed with preterm labor

ANS: C This client is a primipara. The nurse would not expect her to complain excessively of afterbirth pains. This client is a primipara. The nurse would not expect her to complain excessively of afterbirth pains. This client is a multipara and she delivered a macrosomic baby. She is likely to complain of severe afterbirth pains. Although this client is a gravida 4, she is a para 1. The nurse would not expect her to complain excessively of afterbirth pains.

15. A woman who is 12 weeks postpartum presents with the following behavior: she reports severe mood swings and hearing voices, believes her infant is going to die, she has to be reminded to shower and put on clean clothes, and she feels she is unable to care for her baby. These behaviors are associated with which of the following? a. Postpartum blues b. Postpartum depression c. Postpartum psychosis d. Maladaptive mother-infant attachment

ANS: C a. Postpartum blues usually occurs within the first few weeks of the postpartum period. Women experiencing postpartum blues will have mild mood swings, and they can take care of themselves as well as their baby. b. Women with PPD are predominately depressed and do not have mood swings. c. Postpartum psychosis is associated with a break from reality reflected in the woman hearing voices. d. The symptoms reported are reflective of a psychiatric disorder beyond maladaptive attachment.

12. A postpartum nurse has received an exchange report on the four following mother-baby couplets. Based on the provided information, which couplet should the nurse first assess? a. A 25-year-old G2P1 woman who is 36 hours postbirth and is having difficulty breastfeeding her baby girl. Her fundus is firm at the umbilicus, and lochia is moderate to scant. b. A 16-year-old G1P0 who will be discharged in the afternoon. It was reported that she refers to her baby boy as "it" and that she requested to have her baby stay in the nursery so she could sleep. c. A 32-year-old G5P4 woman who delivered a 4500 gram baby boy 2 hours ago after a 20 hour labor that was augmented. It was reported that her fundus is 2 cm above umbilicus with moderate lochia. d. A 28-year-old G2P1 woman who delivered a 3800 gram baby girl by elective cesarean birth. She had spinal anesthesia and was given intrathecal preservative-free morphine for post

ANS: C a. The priority need for this woman is breastfeeding assistance which does not require immediate attention. b. The data indicate that the woman is experiencing a delay in bonding and that social services should become involved. This needs to be done prior to discharge but does not require immediate attention. c. This woman is at risk for hemorrhage (large baby, prolonged labor, augmented labor, high parity, and immediate postpartum). This woman needs to be assessed first to determine whether the fundus is firm and if lochia is within normal limits. d. Based on data provided, this woman is stable, but should be assessed second.

4. On day four following the birth of an average size baby, the nurse would expect the fundus to be at: a. 1 cm below umbilicus b. 2 cm below umbilicus c. 3 cm below umbilicus d. 4 cm below umbilicus

ANS: D Correct. The uterus on the average descends 1 centimeter per day.

15. The perinatal nurse teaches the postpartum woman about the normal process of diuresis that she can expect to occur approximately 6 to 8 hours after birth. A decrease in which of the following hormones is primarily responsible for the diuresis? a. Prolactin b. Progesterone c. Oxytocin d. Estrogen

ANS: D Maternal diuresis occurs almost immediately after birth and urinary output reaches up to 3000 mL each day by the second to fifth postpartum days. After childbirth, a decrease in the level of estrogen naturally occurs and contributes to the diuresis.

5. A nurse is preparing to administer RhoGam to a client who delivered a fetal demise. Which of the following must the nurse check before giving the injection? a. Verify that the direct Coombs test results are positive. b. Check that the fetus was at least 28 weeks' gestation. c. Make sure that the client is at least 3 days postdelivery. d. Confirm that the client is Rh negative.

ANS: D The direct Coombs test is irrelevant, and because the baby has died, the Coombs will likely not be performed. RhoGam should be given no matter how old the fetus was. RhoGam must be administered before 72 hours postpartum. RhoGam is contraindicated for clients who are Rh+ (positive). The nurse must confirm that any client receiving RhoGam is Rh negative.

14. Heather, a postpartum woman who experienced a spontaneous vaginal birth 12 hours ago, describes a headache that is worsening. Heather was given two regular strength acetaminophen (Tylenol) tablets approximately 30 minutes ago but has had no relief from the pain. Several friends and family members are presently visiting Heather. The nurse notes that Heather's pain relief during labor consisted of a single dose of an IM narcotic. The most appropriate nursing action at this time is to: a. Notify Heather's health-care provider about Heather's headache. b. Dim the lights in Heather's room so that she is able to get some rest. c. Ask Heather's visitors to leave now to decrease Heather's environmental stimuli. d. Ask Heather where she is experiencing this headache and to identify the pain score that best describes the intensity of the pain.

ANS: D The nurse should perform routine, comprehensive pain assessments to include onset, location, intensity, quality, characteristics, and aggravating and alleviating factors of the discomfort in order to provide interventions in a timely manner and enhance effectiveness of medications. The nurse should also ask the patient to rate her pain on a standard 0 to 10 pain scale before and after interventions and to identify her own acceptable comfort level on the scale.

3. A client is 1 hour postpartum from a vacuum delivery over a midline episiotomy of a 4500-gram neonate. Which of the following nursing diagnoses is appropriate for this mother? a. Risk for altered parenting b. Risk for imbalanced nutrition: less than body requirements c. Risk for ineffective individual coping d. Risk for fluid volume deficit

ANS: D a. Although the baby is macrosomic, there is no evidence that this mother is high risk for altered parenting. b. This woman's baby is macrosomic—there is no indication that this woman is consuming a diet that is less than body requirements. c. There is no evidence that this mother is high risk for altered coping. d. This client is high risk for fluid volume deficit. Women who deliver macrosomic babies are high risk for uterine atony, which can lead to heavy flow of lochia.

The postpartum nurse is caring for a couple who experienced an unplanned emergency cesarean birth. The nurse observes the following behaviors: Parents are gently touching their newborn. Mother is softly singing to her baby. Father is gazing into his baby's eyes. Based on this data, the correct nursing diagnosis is altered parent-infant bonding related to emergency cesarean birth. Cesarean birth can place the parents at risk for bonding, but based on the observed interaction with their newborn, the parents display positive signs of bonding. (T/F)

ANS: False

True/False The clinic nurse recognizes that the longer an infant is formula fed, the greater is the immunity and resistance the infant will develop against bacterial and viral infections.

ANS: False One of the primary benefits of breastfeeding, not formula feeding, is the decreased incidence of bacterial and viral infections as a result of passive immunity, including the transfer of maternal antibodies.

Bonding is bidirectional from parent to infant and infant to parent. (T/F)

ANS: False Bonding is unidirectional from parent to infant. Attachment is bidirectional.

True/False It is a common custom for traditional Chinese women to bottle feed their infants until their milk comes in.

ANS: True It is common for traditional Chinese women to bottle feed until their milk comes in.

A hematoma is the collection of blood beneath the intact skin layer following an injury to a blood vessel. T/F

ANS: True A hematoma is a localized collection of blood in connective or soft tissue under the skin that follows injury of or laceration to a blood vessel without injury to the overlying tissue. At the time of injury, pressure necrosis and inadequate hemostasis occur.

Eye movements are an example of newborn/infant style of communication. (T/F)

ANS: True Crying, cooing, facial expressions, eye movements, cuddling, and arm and leg movements are all examples of newborn/infant style of communication.

Metritis is an infection that usually starts at the placental site. T/F

ANS: True Metritis is an infection of the endometrium that usually starts at the placental site and spreads to encompass the entire endometrium.

Abruptio placenta is a risk factor for amniotic fluid embolism. T/F

ANS: True Risk factors for amniotic fluid embolism include induction of labor, maternal age over 35, operative delivery, placenta previa, abruptio placenta, polyhydramnios, eclampsia, and cervical or uterine lacerations

The perinatal nurse teaches the postpartum woman that the most critical time to achieve effectiveness from the application of ice packs to the perineum is during the first 24 hours following birth. (T/F)

ANS: True To reduce perineal swelling and pain that result from bruising, ice packs may be applied every 2 to 4 hours. Patients obtain the most relief when ice packs are applied within the first 24 hours after childbirth

9. Approximately 8 hours ago, Juanita, a 32-year-old G1 P0, gave birth after 2 ½ hours of pushing. She required an episiotomy and an assisted birth (forceps) due to the weight and size of her baby (9 lb. 9 oz.). The perinatal nurse is performing an assessment of Juanita's perineal area. A slight bulge is palpated and the presence of ecchymoses to the right of the episiotomy is noted. The area feels "full" and is approximately 4 cm in diameter. Juanita describes this area as "very tender." The most likely cause of these signs and symptoms is: a. Hematoma formation b. Sepsis in the episiotomy site c. Inadequate repair of the episiotomy d. Postpartum hemorrhage

ANS: a A hematoma is a localized collection of blood in connective or soft tissue under the skin that follows injury of or laceration to a blood vessel without injury to the overlying tissue. The most common sign or symptom of a hematoma is unremitting pain and pressure. Upon examination of the perineal or vulvar areas, the nurse may notice discoloration and bulging of the tissue at the hematoma site. If touched, the patient complains of severe tenderness, and the clinician generally describes the tissue as "full."

6. The perinatal nurse recognizes that a risk factor for postpartum depression is: a. Inadequate social support b. Age >35 years c. Gestational hypertension d. Regular schedule of prenatal care

ANS: a Recognized risk factors for postpartum depression include an undesired or unplanned pregnancy, a history of depression, recent major life changes such as the death of a family member, moving to a new community, lack of family or social support, financial stress, marital discord, adolescent age, and homelessness.

1. A woman gave birth to a 3200 g baby girl with an estimated gestational age of 40 weeks. The baby is 1 hour of age. In preparation of giving the baby an injection of vitamin K, the nurse will: a. Explain to the parents the action of the medication and answer their questions. b. Remove the neonate from the room so the parents will not be distressed by seeing the injection. c. Completely undress the neonate to identify the injection site. d. Replace needle with a 21 gauge 5/8 needle.

ANS: a a. It is important to always explain to parents what and why a procedure is being done on the newborn. b. It is best to give parents an option to be with their newborn when giving injections. c. It is best to keep the newborn covered as much as possible to reduce heat loss. d. A 25 gauge 5/8 needle is used for giving injections to full-term neonates.

2. To accurately measure the neonate's head, the nurse places the measuring tape around the head: a. Just above the ears and eyebrows b. Middle of the ear and over the eyes c. Middle of the ear and over the bridge of the nose d. Just below the ears and over the upper lip

ANS: a a. This is the standard measurement for the diameter of the head. b. This is not the standard measurement for the diameter of the head. c. This is not the standard measurement for the diameter of the head. d. This is not the standard measurement for the diameter of the head.

Painful nipples are a major reason why women stop breastfeeding. A primary intervention to decrease nipple irritation is: a. Teaching proper techniques for latching-on and releasing of suction b. Applying hot compresses to breast prior to feeding c. Instructing woman to express colostrum or milk at the end of the feeding session and rub it on her nipples d. Air drying nipples for 10 minutes at the end of the feeding session

ANS: a Feedback a. Correct. All of the answers are correct, but problems with latching-on are a primary cause of nipple irritation. b. All of the answers are correct, but problems with latching-on are a primary cause of nipple irritation. c. All of the answers are correct, but problems with latching-on are a primary cause of nipple irritation. d. All of the answers are correct, but problems with latching-on are a primary cause of nipple irritation.

Which of the following positions for breastfeeding is preferred for a 2-day post-cesarean-birth woman? a. Lying down on side b. Sitting c. Cradle d. Cross-cradle

ANS: a Feedback a. Having the woman lying on her side to breastfeed prevents pressure on her abdomen and the pain that can result from the pressure. b. In this position, the baby is on the woman's abdomen, and this can be painful for the woman. c. In this position, the baby is on the woman's abdomen, and this can be painful for the woman. d. In this position, the baby is on the woman's abdomen, and this can be painful for the woman.

The nurse is advising parents of a full-term neonate being discharged from the hospital regarding car seat safety. Which of the following should be included in the teaching plan? a. Put the car seat facing forward only after the baby reaches 20 pounds. b. The infant car seat should be placed facing the rear seat in the front seat of the car. c. A fist should fit between the straps of the seat and the baby's body. d. Seat belt adjusters should always be used to support infant car seats.

ANS: a Feedback a. It is unsafe for infants to be facing forward until they have reached 20 pounds, even if they are over 1 year of age. b. The baby should be facing the rear of the back seat and not the front seat. c. The straps of the car seat should fit snugly, allowing only two fingers to be inserted between them and the baby. d. Seat belt adjusters that are being sold as adding to a car seat have not been shown to be safe.

A mother of a 10-day-old infant calls the clinic and reports that her baby is having loose, green stools. The mother is breastfeeding her infant. Which of the following is the best nursing action? a. Instruct the woman to bring her infant to the clinic. b. Instruct the woman to decrease the amount of feeding for 24 hours and to call if the stools continue to be loose. c. Explain that this is a normal stool pattern. d. Instruct the woman to eat a bland diet for the next 24 hours and call back if the stools continue to be loose and green.

ANS: a Feedback a. The loose, green stools indicate that the baby is having diarrhea. The infant needs to be evaluated by the primary health provider, because prolonged diarrhea can lead to dehydration and electrolyte imbalance. b. The baby is having diarrhea. Decreasing the amount of feeding can further dehydrate the baby. c. This is not a normal stool pattern; the baby is having diarrhea. d. This neonate needs to be evaluated first, before determining a treatment plan.

The nurse is teaching the parents of a female baby how to change a baby's diapers. Which of the following should be included in the teaching? a. Always wipe the perineum from front to back. b. Remove any vernix caseosa from the labia folds. c. Put powder on the buttocks every time the baby stools. d. Weigh every diaper in order to assess for hydration.

ANS: a Feedback a. To decrease risk of infection from bacteria from the rectum, the perineum of female babies should always be cleansed from front to back. b. Vernix is a natural lanolin that will be absorbed over time. Actively removing the vernix can irritate the baby's skin. c. Powder is not recommended for use on babies. When mixed with urine, powders can produce an irritating paste. d. The number of wet diapers per day should be counted to assess hydration, but weighing diapers of full-term, healthy neonates is not necessary.

A neonatal nurse caring for newborns knows that the best time for a mother to first attempt breastfeeding is during which one of the following stages of activity? a. First period of reactivity b. First period of inactivity and sleep c. Second period of reactivity d. Second period of inactivity and sleep

ANS: a The best stage for initiating breastfeeding is the first period of active, alert wakefulness that the infant displays immediately after birth, which may last from 30 minutes to 2 hours.

The postpartum nurse caring for a 20-year-old G1 P0 woman who 3 hours ago delivered a healthy full-term infant, observes the woman who is lightly touching her baby girl with her fingertips but who seems to be uncomfortable holding her baby close to her body. Which of the following is an accurate interpretation of these observed behaviors? a. The woman is in the initial stage of maternal touch. b. The woman is in the taking-in phase. c. The woman is having difficulty in bonding with her baby. d. The woman needs to be medicated for pain.

ANS: a These are classical signs of the initial stage of Rubin's maternal touch.

The nurse is developing a plan of care for a client who is in the "taking-in" phase after delivering a healthy baby boy. Which of the following should the nurse include in the plan? a. Provide the client with a nutritious meal. b. Teach baby care skills like diapering. c. Discuss the pros and cons of circumcision. d. Counsel her regarding future sexual encounters.

ANS: a a. Mothers are very hungry immediately after delivery. The nurse should provide the client with food.

A 16-year-old woman delivers a healthy, full-term male infant. The nurse notes the following behaviors 2 hours after the birth: Woman holds baby away from her body; woman refers to baby as "he"; woman verbalizes she wanted a baby girl; woman requests that baby be placed in the bassinet so she can eat her lunch. The most appropriate nursing diagnosis for this woman is: a. At risk for impaired parenting related to disappointment with baby as evidenced by verbalizing she wanted a girl b. At risk for impaired parenting related to nonnurturing behaviors as evidenced by holding baby away from body c. At risk for impaired mother-infant attachment as evidenced by woman requesting baby being placed in bassinet d. At risk for impaired mother-infant attachment related to disappointment as evidenced by calling baby "he"

ANS: a a. The potential is for impaired parenting related to disappointment in the gender of the baby.

A woman who gave birth 2 hours ago has a temperature of 37.9°C. Select all of the immediate nursing actions. a. Have patient drink two glasses of fluid over the next hour. b. Explain to the patient that she needs to rest and assist her into a comfortable position. c. Medicate the patient with 500 mg of acetaminophen as per orders. d. Call the patient's physician or midwife to report the elevated temperature.

ANS: a, b A mild temperature elevation within a few hours of birth can be related to dehydration and exhaustion. Acetaminophen is given if the temperature remains elevated after the woman has been hydrated and rested. The physician or midwife is notified if temperature remains elevated after initial interventions.

The clinic nurse teaches expectant mothers about the differences between breast milk and commercially prepared infant formulas. When compared to commercially prepared formulas, breast milk has (select all that apply): a. More carbohydrates b. Less protein c. Fewer nutrients d. Less cholesterol

ANS: a, b Human breast milk contains more carbohydrates, less protein, and more cholesterol than cow's milk or infant formulas. Commercially prepared infant formulas use vegetable oils which are void of cholesterol.

Which of the following actions can decrease the risk for a postpartum infection? (Select all that apply.) a. Diet high in protein and vitamin C b. Increased fluid intake c. Ambulating within a few hours after delivery d. Washing nipples with soap prior to each breastfeeding session

ANS: a, b, c Protein and vitamin C assist with tissue healing. Rehydrating a woman after delivery can assist with decreasing risk for infections. Early ambulation decreases risk for infection by promoting uterine drainage. The woman should not wash her breasts with soap because soap can dry the tissue and increase the woman's risk for tissue breakdown

Which of the following are primary risk factors for subinvolution of the uterus? (Select all that apply.) a. Fibroids b. Retained placental tissue c. Metritis d. Urinary tract infection

ANS: a, b, c Uterine fibroids can interfere with involution. Retained placental tissue does not allow the uterus to remain contracted. Infection in the uterus is a risk factor for subinvolution. UTI does not interfere with involution of the uterus.

A G2 P1 woman who experienced a prolonged labor and prolonged rupture of membranes is at risk for metritis. Which of the following nursing actions are directed at decreasing this risk? (Select all that apply.) a. Instruct woman to increase her fluid intake b. Instruct woman to change her peri-pads after each voiding c. Instruct woman to ambulate in the halls four times a day d. Instruct woman to apply ice packs to the perineum

ANS: a, b, c a. Maintaining adequate hydration can decrease a person's risk for infection. b. Lochia is a media for bacterial growth, so it is important to frequently change the peri-pads. c. Ambulation can decrease the risk of infection by promoting uterine drainage. d. Ice pack therapy is directed at decreasing edema of the perineum and promoting comfort. It has no effect on metriosis.

The perinatal nurse describes infant feeding cues to a new mother. These feeding cues include (select all that apply): a. Vocalizations b. Mouth movements c. Moving the hand to the mouth d. Yawning

ANS: a, b, c The infant demonstrates readiness for feeding when he or she begins to stir, bobs the head against the mattress or mother's neck or shoulder, makes hand-to-mouth or hand-to-hand movements, exhibits sucking or licking, exhibits rooting, and demonstrates increased activity with the arms and legs flexed and the hands in a fist.

Which of the following nursing actions can assist a man in his transition to fatherhood? (Select all that apply.) a. Ask the man to share his ideas of what it means to be a father. b. Demonstrate infant care such as diapering and feeding. c. Engage couple in a discussion regarding each other's expectations of the fathering role. d. Provide the man with information on infant care.

ANS: a, b, c, d Each of these actions can assist the father in his transition. It is important for the man to be able to learn and practice infant care skills in a nonthreatening environment. It is also important for the man to be able to openly talk about his feelings regarding fatherhood and for the couple to identify mutual expectations of the fathering role.

Which of the following factors place a new mother at risk for parenting? (Select all that apply.) a. She is 17 years old. b. Family income is below the average income. c. Her parents live in the same city and are perceived as helpful. d. She dropped out of school at age 13.

ANS: a, b, d Adolescent parents may have a more difficult transition to parenthood because they have not made the transition to adulthood. Financial concerns can hamper the transition to parenthood because the focus of attention may be on where to get money to pay for daily living expenses versus on the care of their newborn. Decreased ability to read and comprehend information regarding child care may hamper the ability to gain knowledge about the care of their child.

Which of the following nursing actions are directed at promoting bonding? (Select all that apply.) a. Providing opportunity for parents to hold their newborn as soon as possible following the birth. b. Providing opportunities for the couple to talk about their birth experience and about becoming parents. c. Promoting rest and comfort by keeping the newborn in the nursery at night. d. Providing positive comments to parents regarding their interactions with their newborn.

ANS: a, b, d Parent bonding can be delayed by prolonged periods of separation from their child. The other three actions support parent bonding with their newborn.

Nursing actions focused at reducing a postpartum woman's risk for cystitis include which of the following? (Select all that apply.) a. Voiding within a few hours post-birth b. Oral intake of a minimum of 1000 mL per day c. Changing peri-pads every 3 to 4 hours or more frequently as indicated d. Reminding the woman to void every 3 to 4 hours while awake

ANS: a, c, d Early voiding helps flush bacteria from the urethra. Voiding every 3 to 4 hours will decrease the risk of bacterial growth in the bladder. Soiled peri-pads are a media for bacterial growth. It is recommend that a postpartum woman drink a minimum of 3000 mL/day to help dilute urine and promote frequent voiding.

General skin care for full-term infants includes which of the following? (Select all that apply.) a. Avoid daily bathing with soap. b. Use a cleanser with an alkaline pH. c. Avoid fragrant soaps. d. Apply petrolatum-based ointments sparingly to dry skin, but avoid head and face.

ANS: a, c, d It is not necessary to bathe an infant daily. Daily bathing with soap can cause dry skin in the infant. The cleanser should be of neutral pH and free of additives such as fragrances that could be irritants.

The nurse is caring for a postpartum woman who gave birth to a healthy, full-term baby girl. She has a 2-year-old son. She voices concern about her older child's adjustment to the new baby. Nursing actions that will facilitate the older son's adjustment to having a new baby in the house would include which of the following? (Select all that apply.) a. Explain to the mother that she can have her son lie in bed with her when he is visiting her in the hospital. b. Teach her son how to change the baby's diapers. c. Assist her son in holding his new baby sister. d. Recommend that she spend time reading to her older son while he sits in her lap.

ANS: a, c, d Two-year-olds enjoy being close to their mothers, including lying next to their mothers or being held. Changing diapers is not viewed as a pleasurable experience and is not developmentally appropriate for a 2-year-old. Children enjoy being able to hold their sibling and feeling "grown up."

7. Karen, a G2, P1, experienced a precipitous birth 90 minutes ago. Her infant is 4200 grams and a repair of a second-degree laceration was needed following the birth. As part of the nursing assessment, the nurse discovers that Karen's uterus is boggy. Furthermore, it is noted that Karen's vaginal bleeding has increased. The nurse's most appropriate first action is to: a. Assess vital signs including blood pressure and pulse. b. Massage the uterine fundus with continual lower segment support. c. Measure and document each perineal pad changed in order to assess blood loss. d. Ensure appropriate lighting for a perineal repair if it is needed.

ANS: b As the primary caregiver, the registered nurse may be the first person to identify excessive blood loss and initiate immediate actions. The nurse should first locate the uterine fundus and initiate fundal massage. Nursing actions performed after the massage are frequent vital sign measurements with an automatic device, measuring the length of time it takes for blood loss to saturate a pad, and assessing for bladder distention.

5. The perinatal nurse teaches the postpartum woman about warning signs regarding development of postpartum infection. Signs and symptoms that merit assessment by the health-care provider include the development of a fever and: a. Breast engorgement b. Uterine tenderness c. Diarrhea d. Emotional lability

ANS: b During the immediate postpartum period, the most common site of infection is the uterine endometrium. This infection presents with a temperature elevation over 101°F, often within the first 24 to 48 hours after childbirth, followed by uterine tenderness and foul-smelling lochia.

he perinatal nurse observes the new mother watching her baby daughter closely, touching her face, and asking many questions about infant feeding. This stage of mothering is best described as: a. Taking in b. Taking hold c. Taking charge d. Taking time

ANS: b As the mother's physical condition improves, she begins to take charge and enters the taking-hold phase where she assumes care for herself and her infant. At this time, the mother eagerly wants information about infant care and shows signs of bonding with her infant. During this phase, the nurse should closely observe mother-infant interactions for signs of poor bonding, and if present, implement actions to facilitate attachment.

The nurse is developing a discharge teaching plan for a 21-year-old first-time mom. This was an unplanned pregnancy. She had a prolonged labor and an early postpartum hemorrhage. The woman plans to breastfeed her baby. She plans to return to work when her baby is 3 months old. Based on this information, the three primary learning needs of this woman are: a. Breastfeeding, bathing of the newborn, and infant safety b. Breastfeeding, storage of milk, and nutrition c. Breastfeeding, contraception, infant safety d. Breastfeeding, storage of milk, and rest

ANS: b Feedback a. These are important learning needs but do not reflect an understanding of learning needs based on early postpartum hemorrhage and returning to work in 3 months. b. Because this is the woman's first time breastfeeding and she plans to return to work, it is important that she feels comfortable with her understanding of breastfeeding and knows how to store her milk when she returns to work. Because she had a postpartum hemorrhage, she needs to learn what foods are high in iron. c. These are important learning needs but do not reflect an understanding of learning needs based on early postpartum hemorrhage and returning to work in 3 months. d. These are important learning needs but do not reflect an understanding of learning needs based on early postpartum hemorrhage.

The perinatal nurse is teaching her new mother about breastfeeding and explains that the most appropriate time to breastfeed is: a. 3 to 4 hours after the last feeding b. When her infant is in a quiet alert state c. When her infant is in an active alert state d. When her infant exhibits hunger-related crying

ANS: b The optimal time to breastfeed is when the baby is in a quiet alert state. Crying is usually a late sign of hunger, and achieving satisfactory latch-on at this time is difficult. Latch-on is proper attachment of the infant to the breast for feeding. The neonate is most alert during the first 1 to 2 hours after an unmedicated birth, and this is the ideal time to put the infant to the breast.

The nurse notes that a new father gazes at his baby for prolonged periods of time and comments that his baby is beautiful and he is very happy having a baby. These behaviors are commonly associated with: a. Bonding b. Engrossment c. Couvade syndrome d. Attachment

ANS: b b. Correct. Characteristics of engrossment are visual awareness of baby, tactile awareness of baby, perception that baby is perfect, strong attraction to baby, feeling of strong elation, and increased self-esteem.

Which of the following are disadvantages of bottle feeding? (Select all that apply.) a. Hampers mother-infant attachment b. Increases cost c. Increases risk of infection d. Increases risk of childhood obesity

ANS: b, c, d Feedback a. Bottle feeding does not interfere with mother-infant attachment. b. The cost of formula is greater than the cost of eating a well-balanced diet. c. Bottle-fed babies are at higher risk for infection because formulas lack the antibiotics that are found in colostrum and human milk. d. There is a relationship between childhood obesity and bottle feeding.

A nurse is going to teach her postpartum patient about newborn bathing, diapering, and swaddling. Which of the following indicates that the nurse incorporated teaching/learning principles in her teaching plans? (Select all that apply.) a. Asked family members to leave b. Turned off TV c. Closed the door of the room d. Administered analgesics a few hours before teaching session

ANS: b, c, d Feedback a. It is often helpful to have family members present, with the woman's permission, so they can also learn about caring for the newborn. b. Turning off the TV decreases the amount of distractions and allows the woman to focus on learning about infant care. c. Closing the door decreases the amount of distractions and allows the woman to focus on learning about infant care. d. Administering analgesia prior to the teaching session will enhance the woman's comfort and facilitate her ability to focus on the teaching session.

The let-down reflex occurs in response to the release of oxytocin. Which of the following can stimulate the release of oxytocin? (Select all that apply.) a. Prolactin release b. Infant suckling c. Infant crying d. Sexual activity

ANS: b, c, d Feedback a. Prolactin stimulates milk production but does not have a direct effect on the release of oxytocin. b. Infant suckling can cause the release of oxytocin. c. Hearing an infant cry can cause the release of oxytocin. d. An orgasm triggers the release of oxytocin.

The nurse is caring for a recently immigrated Chinese woman in the postpartum unit. Based on cultural beliefs and practices of the woman, the nurse would anticipate which of the following? (Select all that apply.) a. The woman prefers cold water for drinking. b. The woman prefers not to shower. c. The woman prefers to have her female relatives care for her baby. d. The woman prefers to have her family bring her food to eat.

ANS: b, c, d In traditional Chinese beliefs and practices, the woman is to rest and female family members take care of the woman and her infant. During the first month, the woman is to avoid yin energy by eating specific foods and avoiding drinking or touching cold water.

The perinatal nurse is teaching the new mother who has chosen to formula feed her infant. Appropriate instructions to be given to this mother include (select all that apply): a. Mix the formula with hot water only. b. Periodically check the nipple for slow flow. c. Prepare only enough formula to last for 24 hours. d. Discard any unused formula that remains in a bottle following use.

ANS: b, c, d Parents should be advised to read and follow the manufacturer's instructions explicitly when preparing the formula, because some require no water and some need to be diluted with water. Cold water should be used to mix the powder, only the amount to be used for each feeding should be prepared, and any unused formula should be discarded. The nipples should be checked periodically during feedings for correct flow and should be replaced regularly.

Typical signs of abusive head trauma (Shaken Baby Syndrome) include which of the following? (Select all that apply.) a. Broken clavicle b. Poor feeding c. Vomiting d. Breathing problems

ANS: b, c, d Symptoms of abusive head trauma are extreme irritability, breathing problems, convulsions, vomiting, and pale or bluish skin.

Which of the following nursing actions are important in the care of a postpartum woman who is at risk for orthostatic hypotension? (Select all that apply.) a. Have patient remain in bed for the first 4 hours postbirth. b. Instruct patient to slowly rise to a standing position. c. Open an ammonia ampule and have the patient smell the ammonia prior to getting out of bed. d. Explain to the patient the cause and incidence of orthostatic hypotension.

ANS: b, d Postpartum women are at risk for orthostatic hypotension during the first few hours postdelivery. Orthostatic hypotension is a sudden drop in the blood pressure when the woman stands up due to decreased vascular resistance in the pelvis. The woman should be instructed to sit on the edge of her bed for a few minutes and then slowly stand up. The nurse or aide should be with the woman the first few times she ambulates. Ammonia ampules are used when the woman faints and is not given prior to fainting.

4. The perinatal nurse accurately defines postpartum hemorrhage by including a decrease in hematocrit levels from pre- to postbirth by: a. 5% b. 8% c. 10% d. 15%

ANS: c Historically, practitioners have defined postpartum hemorrhage as a blood loss greater than 500 mL following a vaginal birth and 1000 mL or more following a cesarean birth. Hematocrit levels that decrease 10% from pre- to postbirth measurements are also included in the definition.

10. The perinatal nurse notifies the physician of the findings related to Juanita's assessment. The first step in care will most likely be to: a. Prepare Juanita for surgery b. Administer intravenous fluids c. Apply ice to the perineum d. Insert a urinary catheter

ANS: c If the hematoma is less than 3 to 5 centimeters in diameter, the physician usually orders palliative treatments such as ice to the area for the first 12 hours along with pain medication. After 12 hours, sitz baths are prescribed to replace the application of ice. However, a hematoma larger than 5 centimeters may require incision and drainage with the possible placement of a drain.

3. Which of the following neonates is at highest risk for cold stress? a. A 36 gestational week LGA neonate b. A 32 gestational week AGA neonate c. A 33 gestational week SGA neonate d. A 38 gestational week AGA neonate

ANS: c a. This neonate should have adequate stores of brown fat. b. This neonate is at risk for cold stress due to gestational age that results in less brown fat. c. This neonate is at risk for cold stress due to gestational age that results in less brown fat. This neonate is at higher risk because this neonate is SGA and has a higher probability of less brown fat than the 32-week AGA. d. This neonate should have adequate stores of brown fat.

A woman on the day of discharge from the postpartum unit requests clean towels so she can take a shower, asks a number of questions regarding breastfeeding, and shares that she is nervous about taking her baby home and not being able to remember everything she has been taught. These are behaviors associated with: a. Bonding b. Taking in c. Taking hold d. Attachment

ANS: c Correct. These are common behaviors of women in the taking-hold phase. Women during this phase have moved to being more independent and able to initiate self-care. They are highly interested in learning about the care of their baby but can easily become frustrated and discouraged when they do not immediately master a new skill.

A postpartum woman, who gave birth 12 hours ago, is breastfeeding her baby. She tells her nurse that she is concerned that her baby is not getting enough food since her milk has not come in. The best response for this patient is: a. "I understand your concern, but your baby will be okay until your milk comes in." b. "Your baby seems content, so you should not worry about him getting enough to eat." c. "Milk normally comes in around the third day. Prior to that, he is getting colostrum which is high in protein and immunoglobulins which are important for your baby's health." d. "You can bottle feed until your milk comes in."

ANS: c Feedback a. Incorrect because it does not inform the woman of what to expect with the stages of milk. b. This conveys a message that the woman's concern is not important. c. This response provides information on the stages of milk production to help the woman understand her newborn's nutritional needs. d. Incorrect response. It is important to avoid bottles until breastfeeding has been well established.

Which of the following statements indicates that a new mother needs additional teaching? a. "I need to supervise my cat when she is in the same room as my baby." b. "I will place my baby on her back when she is sleeping." c. "I will not leave my baby on an elevated flat surface after she is able to turn over on her own." d. "I have asked my husband to install safety latches on the lower cabinets."

ANS: c Feedback a. Pets should always be supervised when in the same room as the infant, because they can intentionally and unintentionally harm the infant. b. True statement. c. Newborns/infants should never be left on an elevated flat surface because they may roll or wiggle and fall off. d. True statement.

A nurse is providing discharge teaching to the parents of a 2-day-old neonate. Which of the following information should be included in the discharge teaching on umbilical cord care? a. Cleanse the cord twice a day with hydrogen peroxide. b. Remove the cord with sterile tweezers if the cord does not fall off by 10 days of age. c. Call the doctor if greenish discharge appears. d. Cover the cord with sterile dressing until it falls off.

ANS: c Feedback a. There is a controversy in the literature regarding what should be used to clean the cord, but hydrogen peroxide is not one of the recommended agents. b. The cord should be allowed to fall off on its own. c. The green drainage may be a sign of infection. d. There is no need to cover the cord.

The nurse is teaching the parents of a 1-day-old baby how to give their baby a bath. Which of the following actions should be included? a. Clean the eye from the outer canthus to the inner canthus. b. Keep the door of the room open to allow for ventilation. c. Gather all supplies before beginning the bath. d. Check the temperature of the water with your fingertip.

ANS: c Feedback a. To decrease the risk of infection, the eyes should be cleaned from the inner to the outer canthus. b. Keeping doors open can cause a drop in baby's temperature by convection. c. If items must be obtained while the bath is being given, the baby may become hypothermic from evaporation resulting from exposure to the air when wet. d. The safest way to check the temperature is with a thermometer or, if none, with the elbow or forearm.

A woman is 3 hours post-early-postpartum hemorrhage of 800 mL at delivery. Select the nursing actions for care of this patient. (Select all that apply.) a. Limit fluid intake to prevent nausea and vomiting. b. Assess fundus every 4 hours during the first 8 hours. c. Explain the importance of preventing an overdistended bladder. d. Provide assistance with ambulation.

ANS: c, d Fluid intake should be increased following a postpartum hemorrhage to decrease the risk of hypovolemia. The fundus should be assessed a minimum of every hour for the first 4 hours following a PPH. The woman needs to know the importance of preventing an overdistended bladder to decrease the risk of further hemorrhage. After postpartum hemorrhage, a woman is at risk for orthostatic hypotension.

Which of the following nursing actions are directed at assisting men in their transition to fatherhood? (Select all that apply.) a. Encourage the woman to take on the major responsibility for infant care. b. Talk to the man, away from his partner, about his expectations of the fathering role. c. Praise the father for his interactions with his infant. d. Provide information on infant care and behavior to both parents.

ANS: c, d It is important to first have the couple discuss with each other their expectations of the fathering role. Once this has occurred, then the woman and nurse need to support the man in his role of infant care. Both parents need to receive information about infant care and infant behaviors, and both parents need to be praised for their interactions with their baby.

8. The nurse is massaging a boggy uterus. The uterus does not respond to the massage. Which medication would the nurse expect would be given first: a. Methergine b. Ergotrate c. Carboprost d. Oxytocin or pitocin

ANS: d If the cause of the hemorrhage is uterine atony, continual fundal massage with lower uterine segment support is mandatory. While one member of the team massages the fundus, another nurse establishes intravenous access with a large bore needle and administers oxytocic drugs in the following order: oxytocin (Pitocin), followed by methylergonovine (Methergine) or ergonovine (Ergotrate), and carboprost (Hemabate).

11. The clinic nurse sees Xiao and her infant in the clinic for their 2-week follow-up visit. Xiao appears to be tired, her clothes and hair appear unwashed, and she does not make eye contact with her infant. She is carrying her son in the infant carrier and when asked to put him on the examining table, she holds him away from her body. The clinic nurse's most appropriate question to ask would be: a. "What has happened to you?" b. "Do you have help at home?" c. "Is there anything wrong with your son?" d. "Would you tell me about the first few days at home?"

ANS: d The well-baby checkup that generally takes place 1 to 2 weeks following the hospital discharge may offer the first opportunity to assess the mother-baby dyad. In this setting, the nurse needs to be alert for subtle cues from the new mother, such as making negative comments about the baby or herself, ignoring the baby's or other children's needs, as well as the mother's physical appearance. In a private area, the nurse should take time to explore the new mother's feelings. A nonthreatening way to open the dialogue might be to say: "Tell me how the first few days at home have gone." This statement provides the new mother with an opportunity to share both positive and negative impressions.

A nurse is making a home visit on the seventh postpartum day to assess a 23-year-old primipara woman and her full-term, healthy baby. Breastfeeding is the method of infant nutrition. The woman tells the nurse that she does not think her milk is good because it looks very watery when she expresses a little before each feeding. The nurse's best response is: a. "This is normal. You only have to be concerned when your baby does not gain weight." b. "What types of foods are you eating? A lack of protein in the diet can cause watery looking breast milk." c. "How much fluid are you drinking while you are nursing your baby? Too much fluid during the feeding session can dilute the breast milk." d. "This is normal and is referred to as foremilk which is higher in water content. Later in the feeding the fat content increases and the milk becomes richer in appearance."

ANS: d Feedback a. Correct information but does not provide information for the woman to understand the different types of milk. b. Incorrect information. c. Incorrect information. d. Correct. This provides an explanation for the consistency of the milk and reassures the woman that the appearance of the milk is normal.

Instructions to a mother of an uncircumcised male infant should include which of the following? a. Instruct her to use a cotton swab to clean under the foreskin. b. Instruct her to clean the penis by retracting the foreskin. c. Instruct her to clean the penis with alcohol. d. Instruct her not to retract the foreskin.

ANS: d Feedback a. Use of cotton swabs or retracting the foreskin can damage the inner layer of the foreskin and cause adhesions. b. Retracting the foreskin can damage the inner layer of the foreskin and cause adhesions. c. Use of alcohol is irritating and painful. d. Parents should not retract the foreskin. The foreskin will fully retract on its own around 5 years of age.

The nurse is teaching the parents of a healthy newborn about infant safety. Which of the following should be included in the teaching plan? a. Water temperature for the infant's bath should be 39°C. b. Crib slates should be a maximum of 3 inches apart. c. Cover electrical outlets once the infant is crawling. d. Remove strings from infant sleepwear.

ANS: d Feedback a. Water temperature should be 38°C. b. Crib slates should be no wider than 2 3/8 inches. c. Electrical covers should be covered before the infant begins to crawl, because infants can roll around to move and reach outlets before they crawl. d. Strings should be removed from bedding, sleepwear, pacifiers, and other objects that come in contact with the infant to decrease the risk of strangulation.

Felicity Chan, a new mother, is accompanied by her mother during her hospital stay on the postpartum unit. Felicity's mother makes specific, various requests of the nurses including bringing warm tea, a cot to sleep on, and that the baby not be bathed at this time. Felicity's mother is also concerned about the amount of work that Felicity may be doing in the provision of infant care. Felicity asks for help with breastfeeding. After Felicity has finished breastfeeding, her mother asks for a bottle so they can warm it and "feed" the baby. How would the perinatal nurse best respond to Felicity's mother in a culturally sensitive way? a. Ask Felicity's mother to leave for 30 minutes to allow for some private time with Felicity to explore her learning needs privately. b. Ask both Felicity and her mother about the preferred infant feeding method, and assess what they already know. c. Convey to Felicity and her mother an un

ANS: d In certain multicultural populations such as India, Thailand, and China, the woman's postpartum confinement lasts for 40 days. During this time, prolonged rest with restricted activity is believed to be essential. The postpartum period is an important time for ensuring future good health, and great emphasis is placed on allowing the mother's body to regain balance after the birth of a child. To provide sensitive, appropriate care, nurses need to adopt a flexible approach when caring for women who embrace non-Western health beliefs and practices. The nurse should advocate for the patient by inquiring about her feeding preferences and by providing information to the mother and her family to support her in her decision.

The perinatal nurse provides information about postpartum depression to all families members because of the potential danger not only to the mother but also to the __________.

ANS: infant The earlier that postpartum depression is recognized and treatment begun, the better is the prognosis for a full recovery. The nurse should involve the family in helping the patient cope with her feelings and assisting with infant care.

A nurse assesses a G2 P1 woman who gave birth to a 4500 gram baby boy 2 hours ago. The nurse notes that the woman's labor was only 2 hours and that the infant was delivered by the labor nurse. The nurse's assessment findings are: Fundus firm and midline at umbilicus Lochia heavy—saturates pad within 15 minutes and bleeding is a steady stream without clots Perineum intact, slight bruising Ice pack on perineum Vital signs are B/P 105/65, P 98, R 20, T 38° Based on this information, the nurse is concerned that the woman has a __________ of the __________ or __________.

ANS: laceration; cervix; vagina Based on the assessment data, the woman is experiencing an early postpartum hemorrhage (PPH). The hemorrhage is most likely not due to uterine atony because the fundus is firm and midline. Laceration of the cervix or vagina is the second most common cause of early PPH. This woman is displaying typical signs and symptoms of laceration of cervix or vagina—firm, midline fundus with steady stream of blood without clots.

The clinic nurse discusses gradual warming of expressed breast milk or formula and cautions against use of the __________ for heating breast milk or formula.

ANS: microwave oven With regard to infant feeding and safety, parents should be taught to warm bottles slowly, never to use a microwave oven to heat breast milk or formula, and never to prop a bottle in the infant's mouth, as this practice creates a choking hazard.

When reviewing potential causes for postpartum hemorrhage with the student nurse, the nurse is sure to include the finding of a(n) __________ bladder.

ANS: overdistended An overdistended bladder, which displaces the uterus above and to the right of the umbilicus, can cause uterine atony and lead to hemorrhage

Postpartum woman are at an increased risk of thrombus formation immediately following birth due to an increased __________ level

ANS: plasma fibrinogen Levels of plasma fibrinogen tend to remain elevated during the first few postpartal weeks. Although this alteration exerts a protective effect against hemorrhage, it increases the patient's risk of thrombus formation

The perinatal nurse understands that the hormonal processes involved in breastfeeding include decreased serum __________ and __________ levels immediately following birth which lead to an increased serum __________ level that causes milk production by the fourth to fifth postpartal days.

ANS: progesterone; estrogen; prolactin Circulating levels of estrogen and progesterone decrease dramatically following delivery of the placenta. The decline in these two hormones signals the anterior pituitary gland to produce prolactin in readiness for lactation.

A postpartum woman who describes symptoms of hallucinations and suicidal thoughts is most likely experiencing postpartum __________.

ANS: psychosis Postpartum psychosis is a rare but severe form of mental illness that severely affects not only the new mother, but the entire family. Postpartum psychosis may present with symptoms of postpartum depression. However, the distinguishing signs of psychosis are hallucinations, delusions, agitation, confusion, disorientation, sleep disturbances, suicidal and homicidal thoughts, and a loss of touch with reality.

The development of a large hematoma can place the postpartum woman at risk for __________.

ANS: shock Upon examination of the perineal or vulvar areas, the nurse may notice discoloration and bulging of the tissue at the hematoma site. If touched, the patient complains of severe tenderness, and the clinician generally describes the tissue as "full." If the hematoma is large, signs of shock may be evident, and the patient may exhibit an absence of lochia and an inability to void.

The perinatal nurse encourages all mothers to place their infants under 12 months of age in the supine position for sleeping, because a leading cause of death for this age group is __________.

ANS: sudden infant death syndrome Sudden infant death syndrome (SIDS) is a leading cause of death among infants between the ages of 1 and 12 months. Having infants sleep on their backs has decreased the risk of SIDS.

The perinatal nurse explains to a new mother that the first sign of a postpartum infection will most likely be an increased __________.

ANS: temperature During the immediate postpartum period, the most common site of infection is the uterine endometrium. This infection presents with a temperature elevation over 101°F (38.4°C), often within the first 24 to 48 hours after childbirth, followed by uterine tenderness and foul-smelling lochia.

Primary breast engorgement is an increase in the __________ and __________ systems that precedes the initiation of milk production.

ANS: vascular; lymphatic Primary breast engorgement is an increase in the vascular and lymphatic systems that precedes the initiation of milk production. Subsequent breast engorgement is related to distention of milk glands.