obstetric nursing: postpartum, Saunders NCLEX Postpartum Questions, POSTPARTUM, OB Chapter 23: Nursing Care of the Newborn and Family, Chapter 23 - Nursing Care of the Newborn and Family (Maternity) EAQ's, Chapter 22: Physiologic and Behavioral Adapt...

A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would further assist the family in their initial period of grief? 1. "What can I do for you?" 2. "Now you have an angel in heaven." 3. "Don't worry, there is nothing you could have done to prevent this from happening." 4. "We will see to it that you have an early discharge so that you don't have to be reminded of this experience."

1 When a loss or death occurs, the nurse should ensure that parents have been honestly told about the situation by their health care provider or others on the health care team. It is important for the nurse to be with the parents at this time and to use therapeutic communication techniques. The nurse must also consider cultural and religious practices and beliefs. The correct option provides a supportive, giving, and caring response. Options 2, 3, and 4 are blocks to communication and devalue the parents' feelings.

The nurse is developing a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse anticipates that which intervention will be prescribed? 1. Administration of anticoagulants 2. Elevation of the affected extremity 3. Ambulation eight to ten times daily 4. Application of ice packs to the affected area

2 Thrombosis that is limited to the superficial veins of the saphenous system is treated with analgesics, rest, and elastic support stockings. Elevation of the affected lower extremity to improve venous return also may be recommended. Warm packs may be prescribed to be applied to the affected area to promote healing. There is usually no need for anticoagulants or anti-inflammatory agents unless the condition persists. Bed rest or limited activity may be prescribed depending on health care provider preference.

The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign would the nurse note if superficial venous thrombosis were present? 1. Paleness of the calf area 2. Coolness of the calf area 3. Enlarged, hardened veins 4. Palpable dorsalis pedis pulses

3 Thrombosis of superficial veins usually is accompanied by signs and symptoms of inflammation, including swelling, redness, tenderness, and warmth of the involved extremity. It also may be possible to palpate the enlarged, hard vein. Clients sometimes experience pain when they walk. Palpable dorsalis pedis pulses is a normal finding.

The nurse is about the give a Type 2 diabetic her insulin before breakfast on her first day postpartum. Which of the following answers best describes insulin requirements immediately postpartum? Lower than during her pregnancy Higher than during her pregnancy Lower than before she became pregnant Higher than before she became pregnant

3. PP insulin requirements are usually significantly lower than prepregnancy requirements. Occasionally, clients may require little to no insulin during the first 24 to 48 hours postpartum.

The nurse is caring for four 1-day postpartum clients. Which client would require further nursing action? 1. The client with mild afterpains 2. The client with a pulse rate of 60 beats/minute 3. The client with colostrum discharge from both breasts 4. The client with lochia that is red and has a foul-smelling odor

4 Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor or an odor similar to menstrual flow. Foul-smelling or purulent lochia usually indicates infection, and these findings are not normal. The other options are normal findings for a 1-day postpartum client.

A client has just had surgery to deliver a nonviable fetus resulting from abruptio placentae. As a result of the abruptio placentae, the client develops disseminated intravascular coagulation (DIC) and is told about the complication. The client begins to cry and screams, "God, just let me die now!" Which client problem should be the priority for the client at this time? 1. Lack of power about the situation 2. Grieving because of the loss of the baby 3. Lack of knowledge regarding what occurred 4. Concern about the loss of the baby and personal health

4 The client expresses that there is no way out of the situation except for death; therefore the client exhibits concern about the loss of the baby and personal health. The data given do not support lack of power. Grieving is a possible client problem at a later time; however, at this time, the concern over the loss should take priority. Lack of knowledge is a possible problem later, but not enough data support it at this point, and it is not the priority.

A nurse is developing a plan of care for a PP woman with a small vulvar hematoma. The nurse includes which specific intervention in the plan during the first 12 hours following the delivery of this client? Assess vital signs every 4 hours Inform health care provider of assessment findings Measure fundal height every 4 hours Prepare an ice pack for application to the area.

4. Application of ice will reduce swelling caused by hematoma formation in the vulvar area. The other options are not interventions that are specific to the plan of care for a client with a small vulvar hematoma.

Which of the following complications is most likely responsible for a delayed postpartum hemorrhage? Cervical laceration Clotting deficiency Perineal laceration Uterine Subinvolution

4. Late postpartum bleeding is often the result of subinvolution of the uterus. Retained products of conception or infection often cause subinvolution. Cervical or perineal lacerations can cause an immediate postpartum hemorrhage. A client with a clotting deficiency may also have an immediate PP hemorrhage if the deficiency isn't corrected at the time of delivery.

The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma? 1. Changes in vital signs 2. Signs of heavy bruising 3. Complaints of intense pain 4. Complaints of a tearing sensation

1 Because the client has had epidural anesthesia and is anesthetized, she cannot feel pain, pressure, or a tearing sensation. Changes in vital signs indicate hypovolemia in an anesthetized postpartum client with vulvar hematoma. Option 2 (heavy bruising) may be seen, but vital sign changes indicate hematoma caused by blood coll

A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention would be most appropriate? 1. Elevate the client's legs. 2. Massage the fundus until it is firm. 3. Ask the client to turn on her left side. 4. Push on the uterus to assist in expressing clots.

2 If the uterus is not contracted firmly, the initial intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage. Elevating the client's legs and positioning the client on the side would not assist in managing uterine atony.

The postpartum nurse is providing instructions to a client after delivery of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function? 1. 3 days postpartum 2. 7 days postpartum 3. On the day of delivery 4. Within 2 weeks postpartum

1 After birth, the nurse should auscultate the client's abdomen in all four quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days postpartum. Surgery, anesthesia, and the use of opioids and pain control agents also contribute to the longer period of altered bowel functions. Options 2, 3, and 4 are incorrect.

The nurse is providing instructions to a client who has been diagnosed with mastitis. Which statement, if made by the client, indicates a need for further instructions? 1. "I need to wear a supportive bra to relieve the discomfort." 2. "I need to stop breast-feeding until this condition resolves." 3. "I can use analgesics to assist in alleviating some of the discomfort." 4. "I need to take antibiotics, and I should begin to feel better in 24 to 48 hours."

2 Mastitis is an infection of the lactating breasts and occurs most often during the second and third weeks after birth, although it may develop at any time during breast-feeding. In most cases, the mother can continue to breast-feed with both breasts. If the affected breast is too sore, the mother can pump the breast gently. Regular emptying of the breast is important to prevent abscess formation. Antibiotic therapy assists in resolving the mastitis within 24 to 48 hours. Additional supportive measures include ice packs, breast supports, and analgesics.

The postpartum nurse is caring for a woman who just delivered a healthy newborn. The nurse should be most concerned with the presence of subinvolution if which occurs? 1. The presence of afterpains 2. Retained placental fragments from delivery 3. An oral temperature of 99.0° F following delivery 4. Increased estrogen and progesterone levels as noted on laboratory analysis

2 Retained placental fragments and infection are the primary causes of subinvolution. When either of these processes is present, the uterus will have difficulty contracting. An oral temperature of 99.0° F after delivery and the presence of afterpains are expected findings following delivery. Option 4 is not a cause of subinvolution and is unrelated to the subject of the question.

A new mother is seen in a health care clinic 2 weeks after giving birth to a healthy newborn infant. The mother is complaining that she feels as though she has the flu and complains of fatigue and aching muscles. On further assessment the nurse notes a localized area of redness on the left breast, and the mother is diagnosed with mastitis. The mother asks the nurse about the condition. The nurse should make which response? 1. "Mastitis usually involves both breasts." 2. "Mastitis can occur at any time during breast-feeding." 3. "Mastitis usually is caused by wearing a supportive bra." 4. "Mastitis is most common for women who have breast-fed in the past."

2 Mastitis is an infection of the lactating breasts and occurs most often during the second and third weeks after birth, although it may develop at any time during breast-feeding. Mastitis is more common in mothers nursing for the first time and usually affects one breast. A supportive bra will not cause mastitis; however, constriction of the breasts from a bra that is too tight may interfere with the emptying of all the ducts and may lead to infection.

The nurse is assessing a client for signs of postpartum depression. Which observation, if noted in the new mother, would indicate the need for further assessment related to this form of depression? 1. The mother is caring for the infant in a loving manner. 2. The mother demonstrates an interest in the surroundings. 3. The mother constantly complains of tiredness and fatigue. 4. The mother looks forward to visits from the father of the newborn.

3 Postpartum depression is not the normal depression that many new mothers experience from time to time. The woman experiencing depression shows less interest in her surroundings and a loss of her usual emotional response toward the family. The woman is also unable to show pleasure or love and may have intense feelings of unworthiness, guilt, and shame. The woman often expresses a sense of loss of self. Generalized fatigue, complaints of ill health, and difficulty in concentrating are also present. The mother would have little interest in food and would experience sleep disturbances.

The nurse is developing a plan of care for a client recovering from a cesarean delivery. Which action should the nurse encourage the client to do to prevent thrombophlebitis? 1. Elevate her legs. 2. Remain on bed rest. 3. Ambulate frequently. 4. Apply warm, moist packs to the legs.

3 Stasis is believed to be a predisposing factor in the development of thrombophlebitis. Because cesarean delivery is also a risk factor for thrombophlebitis, new mothers should ambulate early and frequently to promote circulation and prevent stasis. The other options may be interventions for the client diagnosed with thrombophlebitis. Additionally, bed rest promotes stasis.

A nurse is assessing a client in the 4th stage if labor and notes that the fundus is firm but that bleeding is excessive. The initial nursing action would be which of the following? Massage the fundus Place the mother in the Trendelenburg's position Notify the physician Record the findings

3. If the bleeding is excessive, the cause may be laceration of the cervix or birth canal. Massaging the fundus if it is firm will not assist in controlling the bleeding. Trendelenburg's position is to be avoided because it may interfere with cardiac function.

A new mother received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum her systolic blood pressure has dropped 20 points, her diastolic blood pressure has dropped 10 points, and her pulse is 120 beats/min. The client is anxious and restless. On further assessment, a vulvar hematoma is verified. After notifying the health care provider, what is the nurse's next action? 1. Reassure the client. 2. Monitor fundal height. 3. Apply perineal pressure. 4. Prepare the client for surgery.

4 A hematoma is a localized collection of blood into the tissues of the reproductive sac after delivery. A vulvar hematoma is the most common type . The use of an epidural, prolonged second-stage labor, and forceps delivery are predisposing factors for hematoma formation, and a collection of up to 500 mL of blood can occur in the vaginal area. Although the other options may be implemented, the immediate action is to prepare the client for surgery to stop the bleeding.

After surgical evacuation and repair of a paravaginal hematoma, a client is discharged 3 days postpartum. The nurse determines that the client needs further discharge instructions when the client makes which statement? 1. "I will probably need my mother to help me with housekeeping." 2. "Because I am so sore, I will nurse the baby while lying on my side." 3. "My husband and I will not have intercourse until the stitches are healed." 4. "The only medications I will take are prenatal vitamins and stool softeners."

4 A hematoma is a localized collection of blood into the tissues of the reproductive sac after delivery. A vulvar hematoma is the most common type. The postoperative client will need an antibiotic because she is at increased risk for infection as a result of the break in skin integrity and collection of blood at the hematoma site. Stating that she will need only prenatal vitamins and stool softeners indicates that she requires further teaching. All other options indicate that the mother understands the home care measures after surgical evacuation and repair of a paravaginal hematoma.

A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action? 1. Initiate an intravenous line. 2. Assess the client's blood pressure. 3. Prepare to administer morphine sulfate. 4. Administer oxygen, 8 to 10 L/minute, by face mask.

4 If pulmonary embolism is suspected, oxygen should be administered, 8 to 10 L/minute, by face mask. Oxygen is used to decrease hypoxia. The client also is kept on bed rest with the head of the bed slightly elevated to reduce dyspnea. Morphine sulfate may be prescribed for the client, but this would not be the initial nursing action. An intravenous line also will be required, and vital signs need to be monitored, but these actions would follow the administration of oxygen.

The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction? 1. "I should breast-feed every 2 to 3 hours." 2. "I should change the breast pads frequently." 3. "I should wash my hands well before breast-feeding." 4. "I should wash my nipples daily with soap and water."

4 Mastitis is inflammation of the breast as a result of infection. It generally is caused by an organism that enters through an injured area of the nipples, such as a crack or blister. Measures to prevent the development of mastitis include changing nursing pads when they are wet and avoiding continuous pressure on the breasts. Soap is drying and could lead to cracking of the nipples, and the client should be instructed to avoid using soap on the nipples. The mother is taught about the importance of hand-washing and that she should breast-feed every 2 to 3 hours.

The nurse performs an assessment on a client who is 4 hours postpartum. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. What immediate action should the nurse take? 1. Provide oral fluids and begin fundal massage. 2. Begin hourly pad counts and reassure the client. 3. Elevate the head of the bed and assess vital signs. 4. Assess for hypovolemia and notify the health care provider (HCP).

4 Symptoms of hypovolemia include cool, clammy, pale skin, sensations of anxiety or impending doom, restlessness, and thirst. When these symptoms are present, the nurse should further assess for hypovolemia and notify the HCP. Providing oral fluids and beginning fundal massage and beginning hourly pad counts and reassuring the client will delay necessary treatment. Also, the question gives no indication of the cause of the hypovolemia or that the client is hemorrhaging and that fundal massage is needed. The head of the bed is not elevated in a hypovolemic condition.

The nurse in the postpartum unit is observing the mother-infant bonding process in a client. Which observation, if made by the nurse, indicates the potential for a maladaptive interaction? 1. The mother is observed talking to the newborn. 2. The mother performs cord care for the newborn. 3. The mother verbalizes discomfort with the new role of motherhood. 4. The mother requests that the nurse feed the newborn because she is feeling fatigued.

4 The nurse should be alert to maladaptive interaction in the maternal-infant bonding processes. If the nurse notes that the mother is avoiding interaction with the newborn or is avoiding caring for the newborn, the nurse should suspect the potential for a maladaptive interaction. Talking to the newborn or willingness to perform cord care does not indicate a maladaptive response. Expressing discomfort with the new role of motherhood is a normal, expected process, and it is important for the mother to verbalize concerns.

A postpartum client with deep vein thrombosis is being treated with anticoagulant therapy. The nurse understands that the client's response to treatment will be evaluated by regularly assessing the client for which symptoms? 1. Dysuria, ecchymosis, and vertigo 2. Epistaxis, hematuria, and dysuria 3. Hematuria, ecchymosis, and vertigo 4. Hematuria, ecchymosis, and epistaxis

4 The treatment for deep vein thrombosis is anticoagulant therapy. The nurse assesses for bleeding, which is an adverse effect of anticoagulants. This includes hematuria, ecchymosis, and epistaxis. Dysuria and vertigo are not associated specifically with bleeding.

During the 3rd PP day, which of the following observations about the client would the nurse be most likely to make? The client appears interested in learning about neonatal care The client talks a lot about her birth experience The client sleeps whenever the neonate isn't present The client requests help in choosing a name for the neonate.

1. The third to tenth days of PP care are the "taking-hold" phase, in which the new mother strives for independence and is eager for her neonate. The other options describe the phase in which the mother relives her birth experience.

On which of the postpartum days can the client expect lochia serosa? Days 3 and 4 PP Days 3 to 10 PP Days 10-14 PP Days 14 to 42 PP

2. On the third and fourth PP days, the lochia becomes a pale pink or brown and contains old blood, serum, leukocytes, and tissue debris. This type of lochia usually lasts until PP day 10. Lochia rubra usually last for the first 3 to 4 days PP. Lochia alba, which contain leukocytes, decidua, epithelial cells, mucus, and bacteria, may continue for 2 to 6 weeks PP

Which measure would be least effective in preventing postpartum hemorrhage? Administer Methergine 0.2 mg every 6 hours for 4 doses as ordered Encourage the woman to void every 2 hours Massage the fundus every hour for the first 24 hours following birth Teach the woman the importance of rest and nutrition to enhance healing

3. The fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it to relax. Responses 1, 2, and 4 are all effective measures to enhance and maintain contraction of the uterus and to facilitate healing.

A PP client is being treated for DVT. The nurse understands that the client's response to treatment will be evaluated by regularly assessing the client for: Dysuria, ecchymosis, and vertigo Epistaxis, hematuria, and dysuria Hematuria, ecchymosis, and epistaxis Hematuria, ecchymosis, and vertigo

3. The treatment for DVT is anticoagulant therapy. The nurse assesses for bleeding, which is an adverse effect of anticoagulants. This includes hematuria, ecchymosis, and epistaxis. Dysuria and vertigo are not associated specifically with bleeding.

The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2° F. What is the priority nursing action? 1. Document the findings. 2. Retake the temperature in 15 minutes. 3. Notify the health care provider (HCP). 4. Increase hydration by encouraging oral fluids.

4 The client's temperature should be taken every 4 hours while she is awake. Temperatures up to 100.4° F (38° C) in the first 24 hours after birth often are related to the dehydrating effects of labor. The appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. Although the nurse also would document the findings, the appropriate action would be to increase hydration. Taking the temperature in another 15 minutes is an unnecessary action. Contacting the HCP is not necessary.

Which of the following findings would be a source of concern if noted during the assessment of a woman who is 12 hours postpartum? Postural hypotension Temperature of 100.4°F Bradycardia — pulse rate of 55 BPM Pain in left calf with dorsiflexion of left foot

4. Responses 1 and 3 are expected related to circulatory changes after birth. A temperature of 100.4°F in the first 24 hours is most likely indicative of dehydration which is easily corrected by increasing oral fluid intake. The findings in response 4 indicate a positive Homan sign and are suggestive of thrombophlebitis and should be investigated further.

Perineal care is an important infection control measure. When evaluating a postpartum woman's perineal care technique, the nurse would recognize the need for further instruction if the woman: Uses soap and warm water to wash the vulva and perineum Washes from symphysis pubis back to episiotomy Changes her perineal pad every 2 - 3 hours Uses the peribottle to rinse upward into her vagina

4. Responses 1, 2, and 3 are all appropriate measures. The peribottle should be used in a backward direction over the perineum. The flow should never be directed upward into the vagina since debris would be forced upward into the uterus through the still-open cervix.

What type of milk is present in the breasts 7 to 10 days PP? Colostrum Hind milk Mature milk Transitional milk

4. Transitional milk comes after colostrum and usually lasts until 2 weeks PP

The nurse in a maternity unit is providing emotional support to a client and her husband who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process? 1. "We want to attend a support group." 2. "We never want to try to have a baby again." 3. "We are going to try to adopt a child immediately." 4. "We are okay, and we are going to try to have another baby immediately."

1 A support group can help the parents work through their pain by nonjudgmental sharing of feelings. The correct option identifies a statement that would indicate positive, normal grieving. Although the other options may indicate reactions of the client and significant other, they are not specifically a part of the normal grieving process.

53) Parents can facilitate the adjustment of their other children to a new baby by: Having the children choose or make a gift to give to the new baby upon its arrival home Emphasizing activities that keep the new baby and other children together Having the mother carry the new baby into the home so she can show the other children the new baby Reducing stress on other children by limiting their involvement in the care of the new baby

1. Special time should be set aside just for the other children without interruption from the newborn. Someone other than the mother should carry the baby into the home so she can give full attention to greeting her other children. Children should be actively involved in the care of the baby according to their ability without overwhelming them.

A nurse performs an assessment on a client who is 4 hours PP. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. The nurse prepares immediately to: Assess for hypovolemia and notify the health care provider Begin hourly pad counts and reassure the client Begin fundal massage and start oxygen by mask Elevate the head of the bed and assess vital signs

1. Symptoms of hypovolemia include cool, clammy, pale skin, sensations of anxiety or impending doom, restlessness, and thirst. When these symptoms are present, the nurse should further assess for hypovolemia and notify the health care provider.

Methergine or pitocin are prescribed for a client with PP hemorrhage. Before administering the medication(s), the nurse contacts the health provider who prescribed the medication(s) in which of the following conditions is documented in the client's medical history? Peripheral vascular disease Hypothyroidism Hypotension Type 1 diabetes

1. These medications are avoided in clients with significant cardiovascular disease, peripheral disease, hypertension, eclampsia, or preeclampsia. These conditions are worsened by the vasoconstriction effects of these medications.

The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? 1. A temperature of 100.4° F 2. An increase in the pulse rate from 88 to 102 beats/minute 3. A blood pressure change from 130/88 to 124/80 mm Hg 4. An increase in the respiratory rate from 18 to 22 breaths/minute

2 During the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. An increasing pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. A slight increase in temperature is normal. The blood pressure decreases as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage. The respiratory rate is slightly increased from normal.

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn infant briefly with her fingertips. What should the nurse do to help the woman process the delivery? 1. Encourage the mother to breast-feed soon after birth. 2. Support the mother in her reaction to the newborn infant. 3. Tell the mother that it is important to hold the newborn infant. 4. Document a complete account of the mother's reaction on the birth record.

2 Precipitous labor is labor that lasts 3 hours or less. Women who have experienced precipitous labor often describe feelings of disbelief that their labor progressed so rapidly. To assist the client to process what has happened, the best option is to support the client in her reaction to the newborn infant. Options 1, 3, and 4 do not acknowledge the client's feelings.

The rubella vaccine has been prescribed for a new mother. Which statement should the postpartum nurse make when providing information about the vaccine to the client? 1. "You should avoid sexual intercourse for 2 weeks after administration of the vaccine." 2. "You should not become pregnant for 2 to 3 months after administration of the vaccine." 3. "You should avoid heat and extreme temperature changes for 1 week after administration of the vaccine." 4. "You must sign an informed consent because anaphylactic reactions can occur with the administration of this vaccine."

2 Rubella vaccine is a live attenuated virus that provides immunity for approximately 15 years. Because rubella is a live vaccine, it will act as a virus and is potentially harmful to the organogenesis phase of fetal development. Informed consent for rubella and varicella vaccination in the postpartum period includes information about possible side effects and the risk of teratogenic effects. The client should be informed about the potential effects of this vaccine and the need to avoid becoming pregnant for 2 to 3 months (or as indicated by the health care provider) after administration of the vaccine. Abstinence from sexual intercourse is unnecessary. Heat or extreme changes in temperature have no effect on the person who has been vaccinated. The vaccine is not known to cause anaphylactic reactions.

A nurse is preparing a list of self-care instructions for a PP client who was diagnosed with mastitis. Select all instructions that would be included on the list. Take the prescribed antibiotics until the soreness subsides. Wear supportive bra Avoid decompression of the breasts by breastfeeding or breast pump Rest during the acute phase Continue to breastfeed if the breasts are not too sore.

2, 4, and 5. Mastitis are an infection of the lactating breast. Client instructions include resting during the acute phase, maintaining a fluid intake of at least 3 L a day, and taking analgesics to relieve discomfort. Antibiotics may be prescribed and are taken until the complete prescribed course is finished. They are not stopped when the soreness subsides. Additional supportive measures include the use of moist heat or ice packs and wearing a supportive bra. Continued decompression of the breast by breastfeeding or pumping is important to empty the breast and prevent formation of an abscess.

The nurse is assessing a client who is 6 hours PP after delivering a full-term healthy infant. The client complains to the nurse of feelings of faintness and dizziness. Which of the following nursing actions would be most appropriate? Obtain hemoglobin and hematocrit levels Instruct the mother to request help when getting out of bed Elevate the mother's legs Inform the nursery room nurse to avoid bringing the newborn infant to the mother until the feelings of light-headedness and dizziness have subsided.

2. Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that should caution the nurse to be aware of the client's safety. The nurse should advise the mother to get help the first few times the mother gets out of bed. Obtaining an H/H requires a physicians order.

54) A primiparous woman is in the taking-in stage of psychosocial recovery and adjustment following birth. The nurse, recognizing the needs of women during this stage, should: Foster an active role in the baby's care Provide time for the mother to reflect on the events of and her behavior during childbirth Recognize the woman's limited attention span by giving her written materials to read when she gets home rather than doing a teaching session now Promote maternal independence by encouraging her to meet her own hygiene and comfort needs

2. The focus of the taking-in stage is nurturing the new mother by meeting her dependency needs for rest, comfort, hygiene, and nutrition. Once they are met, she is more able to take an active role, not only in her own care but also the care of her newborn. Women express a need to review their childbirth experience and evaluate their performance. Short teaching sessions, using written materials to reinforce the content presented, are a more effective approach.

The nursing student is assigned to care for a client in the postpartum unit. The coassigned nurse asks the student to identify the most objective method to assess the amount of lochial flow in the client. Which statement, if made by the student, indicates an understanding of this method? 1. "I can estimate the amount of blood loss by gauging the amount of staining on a perineal pad." 2. "I should ask the client to keep a record and document every time the perineal pad is changed." 3. "I should weigh the perineal pad before and after use and note the amount of time between each pad change." 4. "I can look at the perineal pad and gauge the amount of staining and relate it to the amount of time between pad changes."

3 To gather accurate data for comparison, the perineal pads must be weighed both before and after use. Once these weights are gathered, the amount of lochia flow can be accurately determined. Noting the time frame between pad changes and the number of pads used also is an important factor. Gauging the amount of staining does not provide accurate data. Asking the client to obtain the information also may not provide accurate data.

A nurse is preparing to perform a fundal assessment on a postpartum client. The initial nursing action in performing this assessment is which of the following? Ask the client to turn on her side Ask the client to lie flat on her back with the knees and legs flat and straight. Ask the mother to urinate and empty her bladder Massage the fundus gently before determining the level of the fundus.

3. Before starting the fundal assessment, the nurse should ask the mother to empty her bladder so that an accurate assessment can be done. When the nurse is performing fundal assessment, the nurse asks the woman to lie flat on her back with the knees flexed. Massaging the fundus is not appropriate unless the fundus is boggy and soft, and then it should be massaged gently until firm.

When making a visit to the home of a postpartum woman one week after birth, the nurse should recognize that the woman would characteristically: Express a strong need to review events and her behavior during the process of labor and birth Exhibit a reduced attention span, limiting readiness to learn Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn Have reestablished her role as a spouse/partner

3. One week after birth the woman should exhibit behaviors characteristic of the taking-hold stage as described in response 3. This stage lasts for as long as 4 to 5 weeks after birth. Responses 1 and 2 are characteristic of the taking-in stage, which lasts for the first few days after birth. Response 4 reflects the letting-go stage, which indicates that psychosocial recovery is complete.

Following the birth of her baby, a woman expresses concern about the weight she gained during pregnancy and how quickly she can lose it now that the baby is born. The nurse, in describing the expected pattern of weight loss, should begin by telling this woman that: Return to prepregnant weight is usually achieved by the end of the postpartum period Fluid loss from diuresis, diaphoresis, and bleeding accounts for about a 3 pound weight loss The expected weight loss immediately after birth averages about 11 to 13 pounds Lactation will inhibit weight loss since caloric intake must increase to support milk production

3. Prepregnant weight is usually achieved by 2 to 3 months after birth, not within the 6-week postpartum period. Weight loss from diuresis, diaphoresis, and bleeding is about 9 pounds. Weight loss continues during breastfeeding since fat stores developed during pregnancy and extra calories consumed are used as part of the lactation process

The nurse evaluates the ability of a hepatitis B-positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn? 1. The mother requests that the window be closed before feeding. 2. The mother holds the newborn properly during feeding and burping. 3. The mother tests the temperature of the formula before initiating feeding. 4. The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding.

4 Hepatitis B virus is highly contagious and is transmitted by direct contact with blood and body fluids of infected persons. The rationale for identifying childbearing clients with this disease is to provide adequate protection of the fetus and the newborn, to minimize transmission to other individuals, and to reduce maternal complications. The correct option provides the best evaluation of maternal understanding of disease transmission. Option 1 will not affect disease transmission. Options 2 and 3 are appropriate feeding techniques for bottle-feeding, but do not minimize disease transmission for hepatitis B.

The nurse is preparing to care for four assigned clients. Which client is at highest risk for hemorrhage? 1. A primiparous client who delivered 4 hours ago 2. A multiparous client who delivered 6 hours ago 3. A primiparous client who delivered 6 hours ago and had epidural anesthesia 4. A multiparous client who delivered a large baby after oxytocin (Pitocin) induction

4 The causes of postpartum hemorrhage include uterine atony; laceration of the vagina; hematoma development in the cervix, perineum, or labia; and retained placental fragments. Predisposing factors for hemorrhage include a previous history of postpartum hemorrhage, placenta previa, abruptio placentae, overdistention of the uterus from polyhydramnios, multiple gestation, a large neonate, infection, multiparity, dystocia or labor that is prolonged, operative delivery such as a cesarean or forceps delivery, and intrauterine manipulation. The multiparous client who delivered a large fetus after oxytocin induction has more risk factors associated with postpartum hemorrhage than the other clients. In addition, there are no specific data in the client descriptions in options 1, 2, and 3 that present the risk for hemorrhage.

The home care nurse visits a client who has delivered a healthy newborn infant via vaginal delivery. An episiotomy was performed, and the woman has developed a wound infection at the episiotomy site. The nurse provides instructions to the client regarding care related to the infection. Which statement, if made by the mother, indicates a need for further instructions? 1. "I need to take the antibiotics as prescribed." 2. "I need to take warm sitz baths to promote healing." 3. "I need to apply warm compresses to provide comfort." 4. "I need to isolate the infant for 48 hours after beginning the antibiotics."

4 The infant is not isolated routinely from the mother with a wound infection, but the mother must be taught good hand washing techniques and how to protect the infant from contact with contaminated articles. If the mother has a wound infection, broad-spectrum antibiotics will be prescribed for the mother, and she should be instructed to take the antibiotics as prescribed. Analgesics are often necessary, and warm compresses or sitz baths may be used to provide comfort in the area.

A postpartum client is attempting to breast-feed for the first time. The nurse notes that the client has inverted nipples. What nursing action should the nurse take to assist the client in breast-feeding the newborn infant? 1. Massage the breasts, applying gentle pressure on the areolas with the thumb and forefinger. 2. Have the mother grasp her areola between the thumb and forefinger and tug firmly to get the nipple to protrude. 3. Encourage taking a cool shower, allowing the water to run over the breasts, because this will encourage the nipples to protrude. 4. Provide breast shells and assist the mother with using a breast pump before each feeding to make the nipples easier for the newborn infant to grasp.

4 Wearing breast shells and using a breast pump before each feeding will make it easier for the newborn infant to grasp the nipple. Massaging the breast is an appropriate instruction for the mother with engorgement but will not help with resolving inverted nipples. True inverted nipples will retract if the areola is pressed between the thumb and forefinger. Having the client take a cool shower will only make the mother cold, and it has no effect on inverted nipples.

A nurse is providing instructions to a mother who has been diagnosed with mastitis. Which of the following statements if made by the mother indicates a need for further teaching? "I need to take antibiotics, and I should begin to feel better in 24-48 hours." "I can use analgesics to assist in alleviating some of the discomfort." "I need to wear a supportive bra to relieve the discomfort." "I need to stop breastfeeding until this condition resolves."

4. In most cases, the mother can continue to breast feed with both breasts. If the affected breast is too sore, the mother can pump the breast gently. Regular emptying of the breast is important to prevent abscess formation. Antibiotic therapy assists in resolving the mastitis within 24-48 hours. Additional supportive measures include ice packs, breast supports, and analgesics.

After expulsion of the placenta in a client who has six living children, an infusion of lactated ringer's solution with 10 units of pitocin is ordered. The nurse understands that this is indicated for this client because: She had a precipitate birth This was an extramural birth Retained placental fragments must be expelled Multigravida's are at increased risk for uterine atony.

4. Multiple full-term pregnancies and deliveries result in overstretched uterine muscles that do not contract efficiently and bleeding may ensue.

52) Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just wants to sleep. The nurse should: Tell the woman she can rest after she feeds her baby Recognize this as a behavior of the taking-hold stage Record the behavior as ineffective maternal-newborn attachment Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time

4. Response 1 does not take into consideration the need for the new mother to be nurtured and have her needs met during the taking-in stage. The behavior described is typical of this stage and not a reflection of ineffective attachment unless the behavior persists. Mothers need to reestablish their own well-being in order to effectively care for their baby.

Before giving a PP client the rubella vaccine, which of the following facts should the nurse include in client teaching? The vaccine is safe in clients with egg allergies Breast-feeding isn't compatible with the vaccine Transient arthralgia and rash are common adverse effects The client should avoid getting pregnant for 3 months after the vaccine because the vaccine has teratogenic effects

4. The client must understand that she must not become pregnant for 3 months after the vaccination because of its potential teratogenic effects. The rubella vaccine is made from duck eggs so an allergic reaction may occur in clients with egg allergies. The virus is not transmitted into the breast milk, so clients may continue to breastfeed after the vaccination. Transient arthralgia and rash are common adverse effects of the vaccine.

The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction? 1. "I will begin abdominal exercises immediately." 2. "I will notify the health care provider if I develop a fever." 3. "I will turn on my side and push up with my arms to get out of bed." 4. "I will lift nothing heavier than my newborn baby for at least 2 weeks."

1 A cesarean delivery requires an incision made through the abdominal wall and into the uterus. Abdominal exercises should not start immediately after abdominal surgery; the client should wait at least 3 to 4 weeks postoperatively to allow for healing of the incision. Options 2, 3, and 4 are appropriate instructions for the client after a cesarean delivery.

The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client? 1. "You will need to bottle-feed your newborn." 2. "You will need to feed your newborn by nasogastric tube feeding." 3. "You will be able to breast-feed for 6 months and then will need to switch to bottle-feeding." 4. "You will be able to breast-feed for 9 months and then will need to switch to bottle-feeding."

1 Perinatal transmission of human immunodeficiency virus (HIV) can occur during the antepartum period, during labor and birth, or in the postpartum period if the mother is breast-feeding. Clients who have HIV are advised not to breast-feed. There is no physiological reason why the newborn needs to be fed by nasogastric tube.

The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include? 1. The diet should include additional fluids. 2. Prenatal vitamins should be discontinued. 3. Soap should be used to cleanse the breasts. 4. Birth control measures are unnecessary while breast-feeding.

1 The diet for a breast-feeding client should include additional fluids. Prenatal vitamins should be taken as prescribed, and soap should not be used on the breasts because it tends to remove natural oils, which increases the chance of cracked nipples. Breast-feeding is not a method of contraceptio

The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client had a midline episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client? 1. Client pain level 2. Inadequate urinary output 3. Client perception of body changes 4. Potential for imbalanced body fluid volume

1 The priority nursing consideration for a client who delivered 2 hours ago and who has a midline episiotomy and hemorrhoids is client pain level. Most clients have some degree of discomfort during the immediate postpartum period. There are no data in the question that indicate inadequate urinary output, the presence of client perception of body changes, and potential for imbalanced body fluid volume.

Select all of the physiological maternal changes that occur during the PP period. Cervical involution ceases immediately Vaginal distention decreases slowly Fundus begins to descend into the pelvis after 24 hours Cardiac output decreases with resultant tachycardia in the first 24 hours Digestive processes slow immediately.

1 and 3. In the PP period, cervical healing occurs rapidly and cervical involution occurs. After 1 week the muscle begins to regenerate and the cervix feels firm and the external os is the width of a pencil. Although the vaginal mucosa heals and vaginal distention decreases, it takes the entire PP period for complete involution to occur and muscle tone is never restored to the pregravid state. The fundus begins to descent into the pelvic cavity after 24 hours, a process known as involution. Despite blood loss that occurs during delivery of the baby, a transient increase in cardiac output occurs. The increase in cardiac output, which persists about 48 hours after childbirth, is probably caused by an increase in stroke volume because Bradycardia is often noted during the PP period. Soon after childbirth, digestion begins to begin to be active and the new mother is usually hungry because of the energy expended during labor.

Which of the following behaviors characterizes the PP mother in the taking in phase? Passive and dependant Striving for independence and autonomy Curious and interested in care of the baby Exhibiting maximum readiness for new learning

1. During the taking in phase, which usually lasts 1-3 days, the mother is passive and dependent and expresses her own needs rather than the neonate's needs. The taking hold phase usually lasts from days 3-10 PP. During this stage, the mother strives for independence and autonomy; she also becomes curious and interested in the care of the baby and is most ready to learn.

The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with a placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? 1. Infection 2. Hemorrhage 3. Chronic hypertension 4. Disseminated intravascular coagulation

2 In placenta previa, the placenta is implanted in the lower uterine segment. The lower uterine segment does not contain the same intertwining musculature as the fundus of the uterus, and this site is more prone to bleeding. Options 1, 3, and 4 are not risks that are related specifically to placenta previa.

When performing a PP assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which of the following nursing actions is most appropriate? Document the findings Notify the physician Reassess the client in 2 hours Encourage increased intake of fluids.

2. Normally, one may find a few small clots in the first 1 to 2 days after birth from pooling of blood in the vajayjay. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the most appropriate action is to notify the physician.

Which of the following changes best described the insulin needs of a client with type 1 diabetes who has just delivered an infant vaginally without complications? Increase Decrease Remain the same as before pregnancy Remain the same as during pregnancy

2. The placenta produces the hormone human placental lactogen, an insulin antagonist. After birth, the placenta, the major source of insulin resistance, is gone. Insulin needs decrease and women with type 1 diabetes may only need one-half to two-thirds of the prenatal insulin during the first few PP days.

Which of the following complications may be indicated by continuous seepage of blood from the vagina of a PP client, when palpation of the uterus reveals a firm uterus 1 cm below the umbilicus? Retained placental fragments Urinary tract infection Cervical laceration Uterine atony

3. Continuous seepage of blood may be due to cervical or vaginal lacerations if the uterus is firm and contracting. Retained placental fragments and uterine atony may cause subinvolution of the uterus, making it soft, boggy, and larger than expected. UTI won't cause vaginal bleeding, although hematuria may be present.

A nurse is caring for a PP client with a diagnosis of DVT who is receiving a continuous intravenous infusion of heparin sodium. Which of the following laboratory results will the nurse specifically review to determine if an effective and appropriate dose of the heparin is being delivered? Prothrombin time Internationalized normalized ratio Activated partial thromboplastin time Platelet count

3. Anticoagulation therapy may be used to prevent the extension of thrombus by delaying the clotting time of the blood. Activated partial thromboplastin time should be monitored, and a heparin dose should be adjusted to maintain a therapeutic level of 1.5 to 2.5 times the control. The prothrombin time and the INR are used to monitor coagulation time when warfarin (Coumadin) is used.

Which of the following interventions would be helpful to a breastfeeding mother who is experiencing engorged breasts? Applying ice Applying a breast binder Teaching how to express her breasts in a warm shower Administering bromocriptine (Parlodel)

3. Teaching the client how to express her breasts in a warm shower aids with let-down and will give temporary relief. Ice can promote comfort by vasoconstriction, numbing, and discouraging further letdown of milk.

Which type of lochia should the nurse expect to find in a client 2 days PP? Foul-smelling Lochia serosa Lochia alba Lochia rubra

4.

A nurse provides a list of discharge instructions to a client who has delivered a healthy newborn by cesarean delivery. Which statement by the client indicates the need for further teaching? 1. "I can begin abdominal exercises immediately." 2. "I need to notify the health care provider if I develop a fever." 3. "I can't lift anything heavier than my newborn for at least 2 weeks." 4. "I need to turn on my side and push up with my arms to get out of bed."

1 Abdominal exercises should not start immediately following abdominal surgery until 3 to 4 weeks postoperatively to allow for healing of the incision. The other options are appropriate instructions for the client following a cesarean delivery.

A woman infected with the human immunodeficiency virus (HIV) has given birth to a normal-appearing infant, and the nurse provides instructions about newborn infant care. Which statement by the mother indicates a need for further instruction? 1. "I'm going to breast-feed my baby starting right away." 2. "I need to wash my hands before and after bathroom use." 3. "My baby needs to be on antiviral medications for the next 6 weeks." 4. "I am going to contact some support groups listed in my take-home material to help me with everything I'll have to deal with when I get home."

1 Perinatal transmission of HIV to the fetus or neonate of an HIV-positive woman can occur during the antenatal, intrapartal, or postpartum period. HIV transmission can occur during breast-feeding; therefore HIV-positive clients should be encouraged to bottle-feed their neonates. Frequent hand washing is encouraged. Support groups and community agencies can be identified to assist the parents with the newborn's home care, the impact of the diagnosis of HIV infection, and available financial resources. It is recommended that newborn infants of HIV-positive clients receive antiviral medications for the first 6 weeks of life.

The nurse is monitoring a postpartum client who is at risk of developing postpartum endometritis. Which finding, if noted during the first 24 hours after delivery, would support a diagnosis of postpartum endometritis? 1. Abdominal tenderness and chills 2. Increased perspiration and appetite 3. Maternal oral temperature of 100.2° F 4. Uterus two fingerbreadths below midline and firm

1 Signs and symptoms in the postpartum period heralding endometritis include delayed uterine involution, foul-smelling lochia, tachycardia, abdominal tenderness, and temperature elevations up to 104° F. This intrauterine infection may lead to further maternal complications, such as infections of the fallopian tubes, ovaries, and blood (sepsis). Options 2, 3, and 4 represent normal maternal physiological responses in the immediate postpartum period.

The nurse has provided instructions for a postpartum client at risk for thrombosis regarding measures to prevent its occurrence. Which statement, if made by the client, indicates a need for further education? 1. "I should apply my antiembolism stockings after breakfast." 2. "I should avoid prolonged standing or sitting in one position." 3. "I should perform regularly scheduled exercise such as walking." 4. "I should avoid using pillows under my knees to prevent pressure in the back of my knee area."

1 The nurse should instruct the client to apply antiembolism stockings before the client rises in the morning to prevent the venous congestion that will begin as soon as the mother gets up. Circulation can be improved with a regular schedule of activity, preferably walking, and the mother should be instructed to avoid prolonged standing or sitting in one position and avoid placing pillows under the knees because of the risk venous stasis in the lower extremities. The mother also should be encouraged to maintain a fluid intake of at least 2500 mL/day to prevent dehydration and consequent sluggish circulation.

The nurse is assessing a client in the postpartum period and suspects the presence of uterine atony. Which is the initial nursing action? 1. Massage the uterus until firm. 2. Take the client's blood pressure. 3. Contact the health care provider (HCP). 4. Assess the amount of drainage on the peripad.

1 When uterine atony occurs, the initial nursing action would be to massage the uterus until it is firm. If this does not assist in controlling blood loss, then the nurse would contact the HCP. Additionally, once bleeding is under control, the nurse would monitor the vital signs and estimate the amount of blood loss.

The nurse is taking care of a newborn who is not yet circumcised. Which anesthetic agent does the nurse expect the primary health care provider to prescribe? 1 4% lidocaine (LMX4) 2 Morphine (Morphine) 3 Atracurium (Tracrium) 4 Hyoscyamine (Symax)

1 - 4% lidocaine (LMX4) pg 587 - Eutectic mixture of 4% lidocaine (LMX4) is given as a topical anesthetic to the circumcised newborn. Hyoscyamine is used to provide symptomatic relief in various gastrointestinal disorders, such as spasms, peptic ulcers, irritable bowel syndrome, diverticulitis, pancreatitis, colic, and cystitis. Morphine is primarily used to treat both acute and chronic severe pain in a circumcised patient. It is also used to manage pain caused by myocardial infarction and labor. Atracurium (Tracrium) is a muscle relaxant used during circumcision, not before the surgery.

The nurse is taking care of a newborn. The nurse finds out that the infant weighs 1800 g and the mother's HBsAg status is unknown. When should the nurse administer the hepatitis B immune globulin (HGIB) vaccine to the infant? 1 9 hours after the infant is born 2 13 hours after the infant is born 3 14 hours after the infant is born 4 18 hours after the infant is born

1 - 9 hours after the infant is born pg 585 - If the mother's HBsAg status is unknown, then the infant's weight is considered to determine the time for the administration of the HBIG vaccine. The infant weighs 1800 g, so the HBIG vaccine is given within 12 hours after the infant's birth. Therefore the HBIG vaccine should be administered 9 hours after birth, not 13, 14, or 18 hours after. If the mother's HBsAg status is known and the baby weighs more than 2000 g, then the HBIG vaccine can be administered within a week of the newborn's birth. In such a situation, the vaccine can be administered at 13, 14, or 18 hours after the birth of the infant.

The nurse is assessing a newborn with laryngospasms who is crying in a high-pitched voice. The mother's medication history shows the use of anticonvulsants during pregnancy. What is the nurse likely to infer about the newborn's condition? 1 A reduction in calcium levels 2 A reduction in glucose levels 3 A reduction in bilirubin levels 4 A reduction in clotting factors

1 - A reduction in calcium levels pg 580 - Crying in a high-pitched voice and laryngospasms are symptoms of hypocalcemia (reduced calcium levels) in newborns. If the mother was receiving anticonvulsant therapy during pregnancy, there is a greater risk for the child to have lower calcium levels. Irritability and jitteriness are symptoms of reduced glucose levels. The mother's history of diabetes or prolonged labor would increase the risk for hypoglycemia in the newborn. Reduced clotting factors are suspected when the newborn's skin has persisting petechiae for more than 2 days after birth. Reduced bilirubin levels are not found in the newborn. However, an increased level of bilirubin is a common finding.

On a winter morning the nurse finds the skin color of the newborn turning blue. The baby also has difficulty breathing. What should be the immediate nursing interventions to restore a normal condition in the baby? Select all that apply. 1 Administer glucose to the newborn 2 Administer normal saline to the newborn 3 Provide artificial ventilation to the newborn 4 Set the incubator at a temperature above 22° C 5 Administer vitamin K intramuscularly in the newborn

1 - Administer glucose to the newborn 3 - Provide artificial ventilation to the newborn 4 - Set the incubator at a temperature above 22° C pg 572 - The bluish skin color of the newborn is due to difficulty breathing, caused by cold stress. The cold stress increases the respiratory rate in the newborn, thereby depleting the glucose levels. Lack of oxygen causes the bluish tone of the skin. The nurse should administer glucose immediately to the newborn to restore the levels of glucose. Additionally, artificial ventilation is provided to restore the oxygen levels within the baby. The baby should be transferred to an incubator, which is maintained at a temperature of 22° to 26° C, because this helps combat the cold stress. Administration of normal saline cannot restore the glucose levels or promote oxygenation. Vitamin K is generally administered to all newborns to prevent bleeding, but it will not restore the glucose in the newborn or help with thermoregulation.

A patient with a history of gonorrheal infection has just delivered a baby. What immediate intervention should the nurse provide to the newborn to ensure safety? 1 Administer ophthalmic solution 2 Place the newborn in incubator 3 Perform a heelstick puncture test 4 Provide ventilator support to the newborn

1 - Administer ophthalmic solution pg 572 - The nurse should administer erythromycin ophthalmic solution to the newborn within 2 hours of birth to prevent ophthalmia neonatorum caused by gonorrheal infection. Incubation is preferred in order to regulate the body temperature when a neonate has hypothermia. Heelstick puncture is performed to detect abnormalities in blood levels only if the neonate has any infection. Ventilator support is provided if the neonate's heart rate is below 100 beats/min. However, the heart rate is not decreased due to gonorrheal infection.

The primary health care provider (PHP) prescribes ventilator support for a newborn. What finding would the PHP have assessed in the newborn? 1 Bluish discoloration of the skin 2 Yellowish discoloration of the skin 3 Edema in the legs of the newborn 4 Cataracts in the eye of the newborn

1 - Bluish discoloration of the skin pg 572 - Bluish discoloration of the skin is a symptom of cyanosis. It is associated with breathing difficulties, which reduce the oxygen levels in the body. This oxygen deprivation turns the skin blue. The immediate medical intervention includes ventilator support to restore the oxygen levels in the body. Yellow discoloration of the skin signifies increased bilirubin levels, which requires phototherapy; however, it may not require ventilator support. Edematous legs are usually observed in a newborn when the birth process is prolonged. The condition generally resolves in a couple of days after birth. Cataracts are observed in an infant with elevated galactose levels and does not require ventilator support.

As part of their teaching function at discharge, nurses should tell parents that the baby's respiratory status should be protected by which procedures? Select all that apply. 1 Keep a bulb suction available at home. 2 Do not let the infant sleep on his or her back. 3 Keep the infant away from secondhand smoke. 4 Avoid loose bedding, waterbeds, and beanbag chairs. 5 Prevent exposure to people with upper respiratory tract infections.

1 - Keep a bulb suction available at home. 3 - Keep the infant away from secondhand smoke. 4 - Avoid loose bedding, waterbeds, and beanbag chairs. 5 - Prevent exposure to people with upper respiratory tract infections. pg 594 - Infants are vulnerable to respiratory infections; infected people must be kept away. Secondhand smoke can damage lungs. Infants can suffocate in loose bedding and furniture that can trap them. The infant should be laid down to sleep on his or her back for better breathing and to prevent sudden infant death syndrome. A bulb syringe will be useful if the baby needs suctioning of the mouth and nose at home to protect the airway.

A patient vaginally delivers an infant at 36 3/7 weeks gestation. Following delivery, the infant receives a 9/9 Apgar score, and the vital signs obtained are T 97.9, R 62, and HR 156. Based on this assessment, what is the nurse's priority action? 1 Obtain a pulse oximetry value. 2 Suction the infant with a bulb syringe. 3 Place the infant skin to skin with the mother. 4 Continue to observe the newborn in the radiant warmer.

1 - Obtain a pulse oximetry value. pg 582 - The nurse's priority action is to obtain a pulse oximetry value. The newborn is experiencing tachypnea (60 respirations/min or more), which is a sign of abnormal breathing. Furthermore, the birth occurring between 34 0/7 and 36 6/7 weeks of gestation is considered late preterm. The late preterm infant is at an increased risk for many problems, including respiratory distress. Bulb suctioning is used to remove excess mucus. The infant can be placed skin to skin with the mother when the infant is stabilized. Continuing to observe the newborn without further assessment or intervention may result in respiratory distress.

The nurse is caring for an infant who cries in a high-pitched voice. When the crying ceases, the nurse wants to check the blood pressure (BP) of the newborn. What device does the nurse most preferably use? 1 Oscillometric monitor 2 Aneroid sphygmomanometer 3 Mercury sphygmomanometer 4 Ultrasonic Doppler flow meter

1 - Oscillometric monitor pg 557 - An oscillometric monitor is a device used to check the BP in neonates. It is an easy-to-operate digital monitor and does not cause any pain to the infants while it is being used. Aneroid sphygmomanometers and mercury sphygmomanometers are the manual sphygmomanometers and are difficult to use for checking the BP of infants. An ultrasonic Doppler flow meter is the device used for evaluating the hemodynamics of the vascular system (blood flow).

The nurse is assessing a 3-day-old infant with ecchymosis and finds that the condition has not yet healed. The nurse informs the primary health care provider (PHP) of this finding. Which laboratory report would the nurse expect the PHP to order? 1 Platelet count 2 Bilirubin levels 3 Abdominal scan 4 Creatinine levels

1 - Platelet count pg 576 - Ecchymosis is observed in a newborn as a result of injury caused during delivery. This condition usually heals within 2 days of childbirth. If the condition persists for more than 2 days, the PHP will order to test the platelet count to rule out thrombocytopenic purpura. Thrombocytopenic purpura may be the underlying cause for persistent ecchymosis. Bilirubin levels are usually checked when there is a discoloration of the skin, but not for ecchymosis. Abdominal scan and serum creatinine levels are not helpful in determining thrombocytopenic purpura.

The nurse assesses the circumcision site of an infant every 20 minutes for the first hour to check for bleeding. The nurse identifies uncontrollable bleeding at the site. What is the most important nursing intervention? 1 Prepare for blood vessel ligation 2 Clean the bleeding site continuously 3 Administer an analgesic to reduce the pain 4 Apply strong pressure to stop the bleeding

1 - Prepare for blood vessel ligation pg 588 - If the bleeding from the circumcision site is not easily controlled, then the blood vessel may need to be ligated. In this event, the nurse will notify the primary health care provider. Cleaning the bleeding site continuously is recommended to avoid infection. However, it does not reduce bleeding from the circumcision site. Administering an analgesic reduces the pain at the site of the circumcision but does not reduce the loss of blood from the site. The nurse applies gentle pressure with a folded sterile gauze pad. The nurse should not apply strong pressure on the site, because it increases the pain.

The nurse is assessing a neonate who was born on the way to hospital. Which nursing intervention should be performed to prevent apneic spells in the neonate? 1 Provide warmth to the neonate 2 Provide ventilator support to the neonate 3 Provide chest compressions to the neonate 4 Clean the neonate's body with lukewarm water

1 - Provide warmth to the neonate pg 572 - The neonate born on the way to hospital may become hypothermic, so the nurse should gradually warm the neonate's body to avoid apneic spells (insufficiency breathing). Rapid warming may cause apneic spells. Thus the warming process should be gradual. Ventilator support or chest compressions are given when a neonate already has respiratory distress, which is identified by assessing the heart rate. The nurse can use lukewarm water to clear the stains on the neonate's body only after thermal stability is achieved.

The nurse is collecting a neonate's blood sample by the heelstick method. What safety measure will the nurse follow to prevent necrotizing osteochondritis in the neonate? 1 Puncture the skin up to 2.4 mm 2 Repeat the procedure on the other side 3 Apply cold pressure before the puncture 4 Make an imaginary line on the hip before making the puncture

1 - Puncture the skin up to 2.4 mm pg 582 - When performing the heelstick method, the nurse punctures the heel of a neonate at a depth of 2.4 mm to prevent necrotizing osteochondritis. The nurse should apply warm pressure, not cold pressure, before performing the puncture. The nurse would make an imaginary line before puncturing the heel of a newborn, but the line is not on the hip. The nurse would not repeat the test on the other side to prevent necrotizing osteochondritis, but rather will perform the test accurately the first time.

The nurse is assessing the neurologic activity of a neonate. What observation should the nurse report? 1 The ability to suck 2 Head circumference 3 Abdominal movements 4 Head-to-toe measurements

1 - The ability to suck pg 555 - The neurologic assessment of neonates is performed by determining reflex behaviors, such as sucking, rooting, and grasping. The head circumference and the body measurements indicate the physical growth of a neonate. The neonate's abdominal movements are related to the respiratory rate and do not relate to the neonate's neurologic activity.

With regard to umbilical cord care, what should nurses be aware of? 1 The stump can easily become infected. 2 The cord clamp is removed at cord separation. 3 The average cord separation time is 5 to 7 days. 4 A nurse noting bleeding from the vessels of the cord should immediately call for assistance.

1 - The stump can easily become infected. pg 599 - The cord stump is an excellent medium for bacterial growth. The nurse should first check the clamp (or tie) and apply a second one. If the bleeding does not stop, then the nurse calls for assistance. The cord clamp is removed after 24 hours when it is dry. The average cord separation time is 10 to 14 days.

While reading the medical record of a newborn, the nurse learns that the baby is suspected to have Potter syndrome. What observation from the newborn's assessment sheet validates this suspected condition? 1 Urinary output 2 Barrel-shaped chest 3 Webbing around the neck 4 Pinkish coloration of the skin

1 - Urinary output pg 568 - The nurse should check the newborn's urinary output to validate Potter syndrome, because a newborn with this condition does not void in the first 24 hours after birth. Therefore Potter syndrome will reduce the urinary output of the neonate. A barrel-shaped chest is a common finding in any newborn. Webbing around the neck region of the neonate is a primary symptom of Turner syndrome, but it is not associated with Potter syndrome. Pinkish coloration of the skin is a normal finding of any healthy neonate and is not associated with Potter syndrome.

A mother reports that her infant has a severe diaper rash. Upon assessment, the nurse finds that the mother wraps the diaper immediately after bathing the infant, without allowing the skin to properly dry. What medication does the nurse expect the primary health care provider to prescribe to prevent further excoriation? 1 Zinc oxide (Desitin) 2 Oral sucrose (Splenda) 3 Tetracycline (Sumycin) 4 Acetaminophen (Aceta)

1 - Zinc oxide (Desitin) pg 595 - The mother wraps the diaper immediately after bathing without allowing proper drying of the skin. The moisture on the skin results in diaper rash. Zinc oxide ointment (Desitin) can be used to protect the infant's skin from moisture and further excoriation. Oral liquid acetaminophen (Aceta) is a nonopioid analgesic used to treat mild and moderate inflammation. Oral sucrose (Splenda) is used to reduce the pain associated with surgeries. Tetracycline (Sumycin) is administered into the eyes of the infant to prevent ophthalmia neonatorum; it is not used to treat diaper rash.

The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. 1. Wear a supportive bra. 2. Rest during the acute phase. 3. Maintain a fluid intake of at least 3000 mL. 4. Continue to breast-feed if the breasts are not too sore. 5. Take the prescribed antibiotics until the soreness subsides. 6. Avoid decompression of the breasts by breast-feeding or breast pump.

1, 2, 3, 4 Mastitis is an infection of the lactating breast. Client instructions include resting during the acute phase, maintaining a fluid intake of at least 3000 mL/day (if not contraindicated), and taking analgesics to relieve discomfort. Antibiotics may be prescribed and are taken until the complete prescribed course is finished. They are not stopped when the soreness subsides. Additional supportive measures include the use of moist heat or ice packs and wearing a supportive bra. Continued decompression of the breast by breast-feeding or breast pump is important to empty the breast and prevent the formation of an abscess.

The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all that apply. 1. "I should wear a bra that provides support." 2. "Drinking alcohol can affect my milk supply." 3. "The use of caffeine can decrease my milk supply." 4. "I will start my estrogen birth control pills again as soon as I get home." 5. "I know if my breasts get engorged I will limit my breast-feeding and supplement the baby." 6. "I plan on having bottled water available in the refrigerator so I can get additional fluids easily."

1, 2, 3, 6 The postpartum client should wear a bra that is well-fitted and supportive. Breasts may leak between feedings or during coitus, and the client is taught to place a breast pad in the bra. Breast-feeding clients should increase their daily fluid intake; having bottled water available indicates that the postpartum client understands the importance of increasing fluids. If engorgement occurs, the client should not limit breast-feeding, but should breast-feed frequently. Oral contraceptives containing estrogen are not recommended for breast-feeding mothers. Common causes of decreased milk supply include formula use; inadequate rest or diet; smoking by the mother or others in the home; and use of caffeine, alcohol, or other medications.

Which instructions should a nurse provide to a client following delivery regarding care of the episiotomy site to prevent infection? Select all that apply. 1. Report a foul-smelling discharge. 2. Take a warm sitz baths three times a day. 3. Change the perineum pads three times a day. 4. Use warm water to rinse the perineum after elimination. 5. Wipe the perineum from front to back after voiding and defecation.

1, 2, 4, 5 Warm sitz baths and cleansing with warm water are helpful for relieving pain, and these measures will promote cleanliness in the perineal area to prevent infection. The client should also be instructed to wipe the perineum from front to back after voiding and defecation to decrease the risk for contamination with microorganisms from the anus to the vagina. Warm water should be used to rinse the perineum after elimination. The client also should be instructed that the perineal pad should be changed after each elimination and may be changed in between.

A nurse visits a client at home who delivered a healthy newborn 2 days ago. The client is complaining of breast discomfort. The nurse notes that the client is experiencing breast engorgement. Which instructions should the nurse provide to the client regarding relief of the engorgement? Select all that apply. 1. Wear a supportive bra between feedings. 2. Avoid breast-feeding during the time of breast engorgement. 3. Feed the infant at least every 2 hours for 15 to 20 minutes on each side. 4. Apply moist heat to both breasts for about 20 minutes before a feeding. 5. Massage the breasts gently during a feeding, from the outer areas to the nipples.

1, 3, 4, 5 During breast engorgement, the client should be advised to feed the infant frequently, at least every 2 hours, for 15 to 20 minutes on each side. The infant will have an easier time latching on if the client softens her breast and expresses her milk before a feeding. Instruct the client to apply moist heat to both breasts for about 20 minutes before a feeding. This can be done in the shower or with warm wet towels. During a feeding, it is helpful to massage the breast gently from the outer area to the nipple. This helps stimulate the let-down and flow of milk. The client should also be instructed to wear a supportive bra between feedings.

When performing a postpartum check, the nurse should: Assist the woman into a lateral position with upper leg flexed forward to facilitate the examination of her perineum Assist the woman into a supine position with her arms above her head and her legs extended for the examination of her abdomen Instruct the woman to avoid urinating just before the examination since a full bladder will facilitate fundal palpation Wash hands and put on sterile gloves before beginning the check

1. While the supine position is best for examining the abdomen, the woman should keep her arms at her sides and slightly flex her knees in order to relax abdominal muscles and facilitate palpation of the fundus. The bladder should be emptied before the check. A full bladder alters the position of the fundus and makes the findings inaccurate. Although hands are washed before starting the check, clean (not sterile) gloves are put on just before the perineum and pad are assessed to protect from contact with blood and secretions.

A nurse is assessing the fundus in a postpartum woman and notes that the uterus is soft and spongy and is not firmly contracted. The nurse should prepare to implement which interventions? Select all that apply. 1. Massaging the uterus 2. Pushing gently on the uterus 3. Assisting the woman to urinate 4. Rechecking the uterus in 1 hour 5. Checking for a distended bladder 6. Calling the delivery room to schedule an abdominal hysterectomy

1, 3, 5 If the uterus is soft and spongy and is not firmly contracted, the initial nursing action is to massage the fundus gently until it is firm; this will express clots that may have accumulated in the uterus. If the uterus does not remain contracted as a result of massage, the problem may be a distended bladder, which lifts and displaces the uterus and prevents effective contraction of the uterine muscles. The nurse would then check for a distended bladder and assist the woman to urinate. Pushing on an uncontracted uterus could invert the uterus, potentially causing massive hemorrhage and rapid shock. Waiting for 1 hour without intervention could result in bleeding. The health care provider will need to be notified if uterine massage is not helpful. Pharmacological measures may be necessary to maintain firm contraction of the uterus. An abdominal hysterectomy may need to be performed for massive hemorrhage that is uncontrollable. The question presents no data indicating that hemorrhage is a problem. Additionally, the nurse would not schedule an operative procedure.

Which of the following findings would be expected when assessing the postpartum client? Fundus 1 cm above the umbilicus 1 hour postpartum Fundus 1 cm above the umbilicus on postpartum day 3 Fundus palpable in the abdomen at 2 weeks postpartum Fundus slightly to the right; 2 cm above umbilicus on postpartum day 2

1. Within the first 12 hours postpartum, the fundus usually is approximately 1 cm above the umbilicus. The fundus should be below the umbilicus by PP day 3. The fundus shouldn't be palpated in the abdomen after day 10.

The postpartum unit nurse is performing an assessment on a client who is at risk for thrombophlebitis. Which nursing action is indicated in assessing for thrombophlebitis? 1. Palpate for pedal pulses. 2. Ask the client about pain in the calf area. 3. Assess for the presence of vaginal hematoma. 4. Ask the client to ambulate and assess for the presence of pain.

2 Thrombophlebitis is a potential complication in the postpartum period. The client with thrombophlebitis may experience pain in the calf. The remaining options would not determine the presence of thrombophlebitis. Palpating pulses assesses circulation. The presence of a hematoma does not indicate thrombophlebitis. The nurse should not ask the client to ambulate if thrombophlebitis is suspected.

On completing a fundal assessment, the nurse notes the fundus is situated on the client's left abdomen. Which of the following actions is appropriate? Ask the client to empty her bladder Straight catheterize the client immediately Call the client's health provider for direction Straight catheterize the client for half of her uterine volume

1. A full bladder may displace the uterine fundus to the left or right side of the abdomen. Catheterization is unnecessary invasive if the woman can void on her own.

As part of the postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding woman who is one day postpartum. An expected finding would be: Soft, non-tender; colostrum is present Leakage of milk at let down Swollen, warm, and tender upon palpation A few blisters and a bruise on each areola

1. Breasts are essentially unchanged for the first two to three days after birth. Colostrum is present and may leak from the nipples.

A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. When the nurse locates the fundus, she notes that the uterus feels soft and boggy. Which of the following nursing interventions would be most appropriate initially? Massage the fundus until it is firm Elevate the mothers legs Push on the uterus to assist in expressing clots Encourage the mother to void

1. If the uterus is not contracted firmly, the first intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage. Elevating the client's legs and encouraging the client to void will not assist in managing uterine atony. If the uterus does not remain contracted as a result of the uterine massage, the problem may be distended bladder and the nurse should assist the mother to urinate, but this would not be the initial action.

Which of the following factors might result in a decreased supply of breast milk in a PP mother? Supplemental feedings with formula Maternal diet high in vitamin C An alcoholic drink Frequent feedings

1. Routine formula supplementation may interfere with establishing an adequate milk volume because decreased stimulation to the mother's nipples affects hormonal levels and milk production.

A postpartum nurse is preparing to care for a woman who has just delivered a healthy newborn infant. In the immediate postpartum period the nurse plans to take the woman's vital signs: Every 30 minutes during the first hour and then every hour for the next two hours. Every 15 minutes during the first hour and then every 30 minutes for the next two hours. Every hour for the first 2 hours and then every 4 hours Every 5 minutes for the first 30 minutes and then every hour for the next 4 hours.

2

The postpartum client asks the nurse about the occurrence of afterpains. The nurse informs the client that afterpains will be especially noticeable during which activity? 1. Ambulating 2. Breast-feeding 3. Taking sitz baths 4. Arriving home and activities are increased

2 Afterpains are a normal occurrence and result from contractions of the uterus as it reduces in size during involution. Afterpains may be especially noticeable during breast-feeding because oxytocin is released in response to the infant's sucking. The other options are incorrect.

A nurse is caring for a client who has just delivered a newborn following a pregnancy with a placenta previa. When reviewing the plan of care, the nurse should prepare to monitor the client for which risk that is associated with placenta previa? 1. Infection 2. Hemorrhage 3. Chronic hypertension 4. Disseminated intravascular coagulation

2 Because the placenta is implanted in the lower uterine segment, which does not contain the same intertwining musculature as the fundus of the uterus, this site is more prone to bleeding. The other options are not risks that are specifically related to placenta previa.

The nurse is preparing to perform a fundal assessment on a postpartum client. The nurse understands that which is the initial nursing action when performing this assessment? 1. Ask the client to turn on her side. 2. Ask the client to urinate and empty her bladder. 3. Massage the fundus gently before determining the level of the fundus. 4. Ask the client to lie flat on her back, with her knees and legs flat and straight.

2 Before fundal assessment is started, the nurse should ask the mother to empty her bladder so that an accurate assessment can be done. The nurse can then assess the bladder for complete emptying and accurately assess uterine involution. When performing fundal assessment, the woman is asked to lie flat on her back, with the knees flexed. Massaging the fundus is not appropriate unless the fundus is boggy or soft, and then it should be massaged gently until firm.

The nurse who is employed in a prenatal clinic is performing prenatal assessments on clients who are in their first trimester of pregnancy. The nurse is concerned with identifying clients who may be at risk for the development of postpartum complications. Which client would be at the lowest risk for development of postpartum thromboembolic disorders? 1. A 39-year-old woman who reports that she smokes 2. A 26-year-old woman with a family history of thrombophlebitis 3. A 37-year-old woman in her fourth pregnancy who is overweight 4. A 22-year-old woman with a first pregnancy who states that oral contraceptives taken in the past have caused thrombophlebitis

2 Certain factors create a risk for the development of thromboembolic disorders. These include smoking, varicose veins, obesity, a history of thrombophlebitis, women older than 35 years or who have had more than three pregnancies, and women who have had a cesarean birth. From the options presented, a 26-year-old woman with a family history of thrombophlebitis is least likely to develop thromboembolic disorders in the postpartum period

A postpartum client is diagnosed with cystitis. The nurse should plan for which priority nursing action in the care of the client? 1. Providing sitz baths 2. Encouraging fluid intake 3. Placing ice on the perineum 4. Monitoring hemoglobin and hematocrit levels

2 Cystitis is an infection of the bladder. The client should consume 3000 mL of fluids per day if not contraindicated. Sitz baths and ice would be appropriate interventions for perineal discomfort. Hemoglobin and hematocrit levels would be monitored with hemorrhage.

A nurse is monitoring a new mother in the fourth stage of labor for signs of hemorrhage. Which indicates an early sign of excessive blood loss? 1. A temperature of 100.4º F 2. An increased pulse rate of 88 to 102 beats/min 3. A blood pressure change from 130/88 to 124/80 mm Hg 4. An increase in the respiratory rate from 18 to 22 breaths/min

2 During the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. A rising pulse is an early sign of excessive blood loss, because the heart pumps faster to compensate for reduced blood volume. The blood pressure will fall as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage.

The postpartum unit nurse is developing a plan of care for a first-time mother and identifies the need for measures that will promote parent-infant bonding. Which measure should the nurse include in the plan? 1. Use a low-pitched voice to speak to the infant. 2. Encourage the mother to hold the infant when the infant cries. 3. Encourage the parents to allow the infant to sleep in the parental bed. 4. Encourage the mother to allow the nursing staff to care for the infant during her hospital stay until she is discharged.

2 Holding the infant close and allowing the infant to feel the warmth will initiate a positive experience for the mother and will console the infant. The use of a high-pitched voice and participating in infant care are additional methods of promoting parental-infant attachment. Infants should not be allowed to sleep in the parental bed. The parents require time alone as a couple. Additionally, the danger of suffocation of the infant exists if the infant is allowed to sleep between parents.

A nurse is providing instructions to a client who has been diagnosed with mastitis. Which statement made by the client indicates a need for further teaching? 1. "I need to wear a supportive bra to relieve the discomfort." 2. "I need to stop breast-feeding until this condition resolves." 3. "I can use analgesics to assist in alleviating some of the discomfort." 4. "I need to take antibiotics, and I should begin to feel better in 24 to 48 hours."

2 In most cases, the client can continue to breast-feed with both breasts. If the affected breast is too sore, the client can pump the breast gently. Regular emptying of the breast is important to prevent abscess formation. Antibiotic therapy assists in resolving the mastitis within 24 to 48 hours. Additional supportive measures include ice packs, breast supports, and analgesics.

When planning care for a postpartum client that plans to breast-feed her infant, which important piece of information should the nurse include in the teaching plan to prevent the development of mastitis? 1. Offer only one breast at each feeding. 2. Massage distended areas as the infant nurses. 3. Cleanse nipples with a mild antibacterial soap before and after infant feedings. 4. Express and discard milk from the affected breast at the first signs of mastitis.

2 Massaging the distended areas as the infant nurses will encourage complete emptying of the breast and prevent milk stasis. Each breast should be offered at each feeding to prevent milk stasis and ensure adequate milk supply. Soap should not be used on the nipples because of the risk of drying or cracking. If early signs of mastitis occur, the client usually will be instructed to nurse the infant more frequently, because infant sucking is thought to empty the breast more completely.

A pregnant woman who is infected with the human immunodeficiency virus (HIV) delivers a newborn infant, and the nurse provides instructions to help the mother regarding care of the infant. Which statement by the client would indicate the need for further instructions? 1. "I will be sure to wash my hands before and after bathroom use." 2. "I need to breast-feed, especially for the first 6 weeks postpartum." 3. "Support groups are available to assist me with understanding my diagnosis of HIV." 4. "My newborn infant should be on antiviral medications for the first 6 weeks after delivery."

2 Perinatal transmission of HIV to the fetus or neonate of an HIV-positive woman can occur during the antenatal, intrapartal, or postpartum period. HIV transmission can occur during breast-feeding. Therefore HIV-positive clients should be encouraged to bottle-feed their neonates. Frequent handwashing is encouraged. Support groups and community agencies can be identified to assist clients with home care of the newborn infant, the impact of the diagnosis of HIV infection, and finding available financial resources. It is recommended that newborn infants of HIV-positive clients receive antiviral medications for their first 6 weeks of life.

The nurse is caring for a client in the postpartum period immediately after delivery. The nurse performs an assessment on the client and prepares to assess uterine involution by taking which action? 1. Monitoring the vital signs 2. Palpating the uterine fundus 3. Auscultating the bowel sounds 4. Assessing the amount of drainage on the peripad

2 To assess uterine involution, the nurse would palpate the fundal height. Fundal height is measured in fingerbreadths or centimeters in relation to the umbilicus, and this measurement is used to assess the rate of uterine involution. Vital signs and the amount of drainage on the peripad do not indicate uterine involution. Bowel sounds, although they may be diminished in the postpartum period, are not helpful in assessing uterine involution.

The nurse observes generalized petechiae while assessing the skin of a neonate. What further intervention would the primary health care provider most likely request from the nurse? 1 Wrap the neonate in a warm blanket 2 Administer vitamin K intramuscularly 3 Provide ventilator support to the neonate 4 Clean the neonate skin with lukewarm water

2 - Administer vitamin K intramuscularly pg 563/573 - Petechiae rashes observed on a neonate indicate that the neonate has a defect related to clotting factors. Based on this finding the nurse would expect the primary health care provider to order the administration of vitamin K to improve clotting formation. Ventilator support is given when the fetal heart rate (FHR) is noted to be less than 100 beats/min. A neonate is kept in a warm blanket along with the mother to maintain thermoregulation. Cleaning the skin of a neonate does not wipe away petechiae rashes; instead, cleaning is done to remove the bloodstains after birth.

The nurse administers concentrated oral sucrose through the suckling method to a neonate before performing the heelstick method. Why would the nurse do this? 1 To ensure hydration in the infant 2 As a source of comfort to the infant 3 To recognize the reflexes in the infant 4 To increase the glucose level in the infant

2 - As a source of comfort to the infant pg 591 - The heelstick method is used to collect blood to estimate various biologic and chemical materials. The nurse administers oral sucrose to a neonate before performing a painful procedure such as the heelstick method to comfort the neonate. It is not necessary to hydrate the neonate before performing the heelstick method. Hydration of a neonate is usually achieved by administering human milk or infant formula. The infant's glucose levels are maintained by infusing dextrose; it is not used to recognize reflexes in infant.

Following circumcision of a newborn, the nurse provides instructions to his or her parents regarding postcircumcision care. What should the nurse tell the parents to do? 1 Apply topical anesthetics with each diaper change 2 Expect a yellowish exudate to cover the glans after the first 24 hours 3 Apply constant pressure to the site if bleeding occurs and call the physician 4 Change the diaper every 2 hours and cleanse the site with soap and water or baby wipes

2 - Expect a yellowish exudate to cover the glans after the first 24 hours pg 588 - Parents should be taught that a yellow exudate will develop over the glans and should not be removed. Topical anesthetics are applied before the circumcision. Infant-comforting techniques are generally sufficient following the procedure. The diaper is changed frequently, but the site is cleansed with warm water only because soap and baby wipes can cause pain/burning and irritation at the site. Intermittent pressure is applied if bleeding occurs.

The nurse observes increased bilirubin levels in the laboratory reports of a newborn. Which complication does the nurse expect in the newborn if this condition is poorly monitored? 1 Syndactyly 2 Kernicterus 3 Rectal fistula 4 Down syndrome

2 - Kernicterus pg 575 - Very high levels of bilirubin cause kernicterus. Bilirubin is a yellow pigment that is produced in the body during the normal recycling of old red blood cells (RBCs). High levels of bilirubin in the body can cause the skin to look yellow, a condition known as jaundice. Syndactyly is a condition where two or more digits are fused together. It is not associated with increased bilirubin levels. Rectal fistula is caused by the absence of the anal opening in the newborn. Down syndrome is a chromosome defect and is not associated with increased bilirubin levels.

The nurse is caring for a two-day-old term infant who was circumcised six hours ago. He is restless and fussy and refuses to breastfeed. The nurse attempts nonpharmacologic interventions with minimal results. What medication does the nurse expect the primary health care provider to order as an analgesic for the newborn? 1 Oral sucrose 2 Liquid acetaminophen 3 Intravenous (IV) fentanyl 4 Topical prilocaine-lidocaine (EMLA)

2 - Liquid acetaminophen pg 588 - Oral liquid acetaminophen is a nonopioid analgesic that may be used to reduce pain following circumcision. It may be administered every 4 hours, not to exceed 75 mg/kg/day. Oral sucrose may be given before circumcision along with 4% lidocaine as a topical anesthetic; it is not used to alleviate postcircumcision pain. Prilocaine-lidocaine (EMLA) is a local anesthetic applied topically prior to circumcision. Bolus or continuous IV infusion of opioids, like fentanyl, provide effective pain control with low incidence of adverse effects; however, these are most often used for more severe pain.

Upon assessing the laboratory reports of an infant, the nurse finds an abnormality in the infant's bone development. The nurse instructs the parents to perform periodic checkups and monitor the growth of the infant. What did the nurse find in the infant's laboratory reports? 1 Low methionine levels 2 Low thyroxine (T4) levels 3 Decreased galactose levels 4 Decreased phenylalanine levels

2 - Low thyroxine (T4) levels pg 563 - Low T4 levels may retard the growth of the infant. Therefore it is important to monitor the regular growth of the infant, particularly pertaining to bone growth. Low levels of galactose may affect the immune system in the body, making it nonfunctional. Low methionine levels may cause liver damage. Low phenylalanine levels lead to intellectual disability in infants. However, low levels of galactose, methionine, and phenylalanine do not affect the bone growth of the child. Therefore it is not suggested to monitor the bone growth if any of these chemical molecules decreases in the infant.

The nurse is performing an evaluation and screening of a newborn. To estimate the blood glucose levels, the nurse collects blood from the infant by the heelstick method. What nursing intervention would be accurate while performing the heelstick method? 1 Make a puncture no deeper than 3 mm into the neonate's heel 2 Make a puncture no deeper than 2.4 mm into the neonate's heel 3 Make a puncture no deeper than 2 mm on the right side of the neonate's heel 4 Make a puncture no deeper than 1 mm on the right side of the neonate's heel

2 - Make a puncture no deeper than 2.4 mm into the neonate's heel pg 582 - To avoid necrotizing osteochondritis in the newborn, the puncture is made no deeper than 2.4 mm in the heel. Therefore making a puncture 2 mm deep in the heel is the correct intervention. If the puncture is made 3 mm deep into the heel, it would result in lancet penetration of the bone. Therefore the nurse would not make a puncture 3 mm deep. The heelstick method is performed in the heel, not on the sides of the heel. Therefore making a puncture that is 2 mm or 1 mm deep on the right side of the heel is an incorrect action.

The nurse is caring for an infant with candidiasis. Despite being treated with topical clotrimazole (Pedesil), the infection persists. Which medication does the primary health care provider prescribe? 1 Oral fentanyl (Sublimaze) 2 Oral nystatin (Mycostatin) 3 Topical miconazole (Desenex) 4 Morphine infusion (Duramorph)

2 - Oral nystatin (Mycostatin) pg 595 - Persistence of the candidiasis even after antifungal therapy indicates any gastrointestinal source of infection. To eliminate any gastrointestinal source of candidiasis, oral nystatin (Mycostatin) is prescribed. Oral fentanyl (Sublimaze) is an analgesic and does not combat the infection in the body. Topical miconazole (Desenex) is of no use in this condition, because the infection is internal and it is used to treat fungal infections on the skin. Intravenous (IV) morphine infusion (Duramorph) is an analgesic. It is not used to treat candidiasis.

The nurse is assessing a preterm baby and observes dark red skin color with harlequin signs on the skin. What does the nurse infer that the baby has from these findings? 1 Hypotension 2 Polycythemia 3 Hyperthermia 4 A neurologic disorder

2 - Polycythemia pg 563 - The dark red color skin of the newborn with harlequin signs indicates polycythemia. Polycythemia is common in preterm infants because of the presence of fetal red blood cells (RBCs). The presence of hypotension in the infant is indicated by gray coloration of the skin. The presence of hyperthermia in a newborn is indicated by blue coloration (cyanosis) of the skin. Neurologic disorders are associated with cyanosis but not with polycythemia.

The nurse evaluates the blood pressure (BP) of a neonate and suspects a cardiac defect. What recordings of the neonate's BP confirm a cardiac defect? 1 The BP in the lower extremities is 60/40 mm Hg and in the upper extremities is 70/50 mm Hg. 2 The BP in the lower extremities is 50/40 mm Hg and in the upper extremities is 80/70 mm Hg. 3 The BP in the lower extremities is 70/40 mm Hg and in the upper extremities is 60/40 mm Hg. 4 The BP in the lower extremities is 80/40 mm Hg and in the upper extremities is 70/60 mm Hg.

2 - The BP in the lower extremities is 50/40 mm Hg and in the upper extremities is 80/70 mm Hg. pg 557 - Systolic BP should be 60 to 80 mm Hg, and diastolic BP should be 40 to 50 mmHg. When the recordings are varied by 20 mm Hg in both the extremities, it implies that the neonate has a cardiac defect, such as coarctation of the aorta. If the BP of the lower extremities is 50/40 mm Hg and that of the upper extremities is 80/70 mm Hg, it indicates that the neonate has a cardiac defect, such as coarctation of the aorta. The same recordings on all the extremities signify that the neonate's heart functions properly. Variations of 10 mm Hg are still considered a normal finding in a neonate.

The nurse is assessing a neonate who has undergone phototherapy. The nurse finds the transcutaneous bilirubinometry (TcB) reading to be 13 mg/dL. What should the nurse infer about the neonate from these findings? 1 The neonate has not been breastfed. 2 The neonate may require blood transfusion. 3 The neonate requires intravenous dextrose infusion. 4 The neonate needs to receive oral acetaminophen (Tylenol).

2 - The neonate may require blood transfusion. pg 577 - A transcutaneous bilirubinometry (TcB) reading greater than 12 mg/dL indicates excessive serum unconjugated bilirubin levels. If these levels persist even after the phototherapy, the neonate may require blood transfusion to decrease the serum unconjugated bilirubin levels. Breastfeeding the neonate increases the gastric motility and eliminates excess bilirubin. Therefore breastfeeding is encouraged during hyperbilirubinemia. Oral acetaminophen (Tylenol) is given to alleviate the pain in a neonate associated with procedures such as circumcision. Dextrose infusion is administered when a neonate has low glucose levels.

Newborns are at high risk for injury if appropriate safety precautions are not implemented. What should be parents taught to do? 1 Avoid use of pacifiers 2 Use a rear-facing car seat 3 Use a crib with side rail slats that are no more than 3 inches apart 4 Place the newborn on the abdomen (prone) after feeding and for sleep

2 - Use a rear-facing car seat pg 594 - The newborn should be in a rear-facing infant car safety seat from birth until 2 years of age or until exceeding the car seat's limits for height and weight. The prone position is no longer recommended because it may interfere with chest expansion and lead to sudden infant death syndrome. Approved pacifiers are safe to use and fulfill a newborn's need to suck. If the newborn is breastfed, the use of pacifiers should be delayed until breastfeeding is well established to avoid the development of nipple confusion. Slats in a crib should be no more than 2 inches apart.

A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply. 1. Breast-feeding needs to be stopped for 3 months. 2. Pregnancy needs to be avoided for 1 to 3 months. 3. The vaccine is administered by the subcutaneous route. 4. Exposure to immunosuppressed individuals needs to be avoided. 5. A hypersensitivity reaction can occur if the client has an allergy to eggs. 6. The area of the injection needs to be covered with a sterile gauze for 1 week.

2, 3, 4, 5 Rubella vaccine is administered to women who have not had rubella or women who are not serologically immune. The vaccine may be administered in the immediate postpartum period to prevent the possibility of contracting rubella in future pregnancies. The live attenuated rubella virus is not communicable in breast milk; breast-feeding does not need to be stopped. The client is counseled not to become pregnant for 1 to 3 months after immunization as specified by the health care provider because of a possible risk to a fetus from the live virus vaccine; the client must be using effective birth control at the time of the immunization. The client should avoid contact with immunosuppressed individuals because of their low immunity toward live viruses and because the virus is shed in the urine and other body fluids. The vaccine is administered by the subcutaneous route. A hypersensitivity reaction can occur if the client has an allergy to eggs because the vaccine is made from duck eggs. There is no useful or necessary reason for covering the area of the injection with a sterile gauze.

After receiving report at the beginning of the 0700 shift, the nurse must decide in what order the clients should be assessed. How would the nurse plan assessments? Arrange the clients in the order that they should be assessed. All options must be used. Drag the text in the left column to the correct order in the right column. An 8-hour post-vaginal delivery gravida 2, para 2 client who is scheduled for a bilateral tubal ligation at 1200 today and has a continuous peripheral intravenous (IV) solution of 5% dextrose in lactated Ringer's solution (D5LR) with 20 milliunits of oxytocin (Pitocin) infusing at 125 mL/hr. 1 A 12-hour post-cesarean section delivery of a gravida 3, para 3, who reports a return of feeling in her lower extremities as well as a sensation of wetness underneath her buttocks. 2 A 48-hour post-cesarean section delivery of a gravida 1, para 1, who reports not yet having a bowel movement since delivery and requests a stool softener. 3 A 24-hour post-vaginal delivery of a gravida 4, para 4, who is complaining of abdominal cramping after nursing her baby and requesting ibuprofen (Motrin).

2, 4, 1, 3 The 12-hour post-cesarean section delivery client should be assessed first because she is reporting a sensation of wetness; this could be excessive bleeding. The 24-hour post-vaginal delivery client is complaining of pain, which can be treated easily with oral medications; therefore this client should be assessed next. The 8-hour post-vaginal delivery client who is scheduled for a bilateral tubal ligation has an IV infusing of oxytocin, which will facilitate uterine involution, thereby promoting uterine contractions and minimal bleeding. A baseline assessment must be conducted preoperatively for a bilateral tubal ligation; however, the scheduled operative time is 5 hours away. The client who had cesarean section delivery 48 hours ago is assessed last as she is the farthest out from delivery, and the effectiveness of a stool softener will be achieved over time with continued administration.

The nurse is providing nutritional counseling to a new mother who is breast-feeding her newborn. The nurse should instruct the client that her calorie needs should increase by approximately how many calories a day? 1. 100 2. 300 3. 500 4. 1000

3 If the client is breast-feeding, her calorie needs increase by approximately 500 cal/day. The client should also be instructed regarding the need for increased fluids and the need for prenatal vitamins and iron supplements.

The nurse examines a woman one hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action would be to: Place her on a bedpan to empty her bladder Massage her fundus Call the physician Administer Methergine 0.2 mg IM which has been ordered prn

2. A boggy or soft fundus indicates that uterine atony is present. This is confirmed by the profuse lochia and passage of clots. The first action would be to massage the fundus until firm, followed by 3 and 4, especially if the fundus does not become or remain firm with massage. There is no indication of a distended bladder since the fundus is midline and below the umbilicus.

A PP nurse is providing instructions to a woman after delivery of a healthy newborn infant. The nurse instructs the mother that she should expect normal bowel elimination to return: One the day of the delivery 3 days PP 7 days PP within 2 weeks PP

2. After birth, the nurse should auscultate the woman's abdomen in all four quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days PP. Surgery, anesthesia, and the use of narcotics and pain control agents also contribute to the longer period of altered bowel function.

A nurse is monitoring a new mother in the PP period for signs of hemorrhage. Which of the following signs, if noted in the mother, would be an early sign of excessive blood loss? A temperature of 100.4*F An increase in the pulse from 88 to 102 BPM An increase in the respiratory rate from 18 to 22 breaths per minute A blood pressure change from 130/88 to 124/80 mm Hg

2. During the 4th stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. A rising pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. The blood pressure will fall as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage. A slight rise in temperature is normal. The respiratory rate is increased slightly.

Which of the following physiological responses is considered normal in the early postpartum period? Urinary urgency and dysuria Rapid diuresis Decrease in blood pressure Increase motility of the GI system

2. In the early PP period, there's an increase in the glomerular filtration rate and a drop in the progesterone levels, which result in rapid diuresis. There should be no urinary urgency, though a woman may feel anxious about voiding. There's a minimal change in blood pressure following childbirth, and a residual decrease in GI motility.

The nurse is assessing the lochia on a 1 day PP patient. The nurse notes that the lochia is red and has a foul-smelling odor. The nurse determines that this assessment finding is: Normal Indicates the presence of infection Indicates the need for increasing oral fluids Indicates the need for increasing ambulation

2. Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor. Foul smelling or purulent lochia usually indicates infection, and these findings are not normal. Encouraging the woman to drink fluids or increase ambulation is not an accurate nursing intervention.

Methergine or pitocin is prescribed for a woman to treat PP hemorrhage. Before administration of these medications, the priority nursing assessment is to check the: Amount of lochia Blood pressure Deep tendon reflexes Uterine tone

2. Methergine and pitocin are agents that are used to prevent or control postpartum hemorrhage by contracting the uterus. They cause continuous uterine contractions and may elevate blood pressure. A priority nursing intervention is to check blood pressure. The physician should be notified if hypertension is present.

A PP nurse is assessing a mother who delivered a healthy newborn infant by C-section. The nurse is assessing for signs and symptoms of superficial venous thrombosis. Which of the following signs or symptoms would the nurse note if superficial venous thrombosis were present? Paleness of the calf area Enlarged, hardened veins Coolness of the calf area Palpable dorsalis pedis pulses

2. Thrombosis of the superficial veins is usually accompanied by signs and symptoms of inflammation. These include swelling of the involved extremity and redness, tenderness, and warmth.

The nurse is developing a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery? 1. Assess vital signs every 4 hours. 2. Measure fundal height every 4 hours. 3. Prepare an ice pack for application to the area. 4. Inform the health care provider of assessment findings.

3 A hematoma is a localized collection of blood into the tissues of the reproductive sac after delivery. Vulvar hematoma is the most common. Application of ice reduces swelling caused by hematoma formation in the vulvar area. Options 1, 2, and 4 are not interventions that are specific to the plan of care for a client with a small vulvar hematoma.

The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action? 1. Record the findings. 2. Massage the fundus. 3. Notify the health care provider (HCP). 4. Place the client in Trendelenburg's position.

3 If bleeding is excessive, the cause may be laceration of the cervix or birth canal. Massaging the fundus if it is firm would not assist in controlling the bleeding. Trendelenburg's position should be avoided because it may interfere with cardiac and respiratory function. Although the nurse would record the findings, the initial nursing action would be to notify the HCP.

A postpartum woman with mastitis in the right breast complains that the breast is too sore for her to breast-feed her infant. The nurse should tell the client to implement which measure? 1. Pump both breasts and discard the milk. 2. Bottle-feed the infant on a temporary basis. 3. Breast-feed from the left breast and gently pump the right breast. 4. Stop breast-feeding from both breasts until this condition resolves.

3 In most cases, the mother can continue to breast-feed with both breasts. If the affected breast is too sore, the mother can pump the breast gently. Regular emptying of the breast is important to prevent abscess formation. If an abscess forms and ruptures into the ducts of the breast, breast-feeding will need to be discontinued and a pump should be used to empty the breast (but the milk should be discarded). Options 1, 2, and 4 are incorrect.

A client arrives at the postpartum unit after delivery of her infant. On performing an assessment, the nurse notes that the client is shaking uncontrollably. Which nursing action would be appropriate? 1. Massage the fundus. 2. Contact the health care provider. 3. Cover the client with a warm blanket. 4. Place the client in Trendelenburg's position.

3 In the postpartum period, a woman may experience a shaking, uncontrollable chill immediately after birth. The exact cause of this fairly common event is not known; however, it is thought to be associated with a nervous system reaction such as a vasovagal response. If the chill is not associated with an elevated temperature, it is of no clinical significance. The appropriate nursing action would be to provide a warm blanket to the client and a warm drink if this is not contraindicated.

The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 1 hour. How should the nurse document this finding? 1. Scant 2. Light 3. Heavy 4. Excessive

3 Lochia is the discharge from the uterus in the postpartum period; it consists of blood from the vessels of the placental site and debris from the decidua. The following can be used as a guide to determine the amount of flow: scant = less than 2.5 cm (<1 inch) on menstrual pad in 1 hour; light = less than 10 cm (<4 inches) on menstrual pad in 1 hour; moderate = less than 15 cm (<6 inches) on menstrual pad in 1 hour; heavy = saturated menstrual pad in 1 hour; and excessive = menstrual pad saturated in 15 minutes.

A nurse is checking lochia discharge in a woman in the immediate postpartum period. The nurse notes that the lochia is bright red and contains some small clots. Based on this data, the nurse should make which interpretation? 1. The client is hemorrhaging. 2. The client needs to increase oral fluids. 3. The client is experiencing normal lochia discharge. 4. The client's health care provider needs to be notified of the finding.

3 Lochia, the uterine discharge present after birth, initially is bright red and may contain small clots. During the first 2 hours after birth, the amount of uterine discharge should be approximately that of a heavy menstrual period. After that time, the lochial flow should steadily decrease, and the color of the discharge should change to a pinkish red or reddish brown. Because this is a normal, expected occurrence, options 1, 2, and 4 are incorrect.

When performing a postpartum assessment on a client, a nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate? 1. Document the findings. 2. Reassess the client in 2 hours. 3. Notify the health care provider. 4. Encourage increased oral intake of fluids.

3 Normally, a few small clots may be noted in the lochia in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the appropriate action is to notify the HCP. Reassessing the client in 2 hours would delay necessary treatment. Increasing oral intake of fluids would not be a helpful action in this situation.

The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action would be most appropriate? 1. Raise the head of the client's bed. 2. Obtain hemoglobin and hematocrit levels. 3. Instruct the client to request help when getting out of bed. 4. Inform the nursery room nurse to avoid bringing the newborn to the client until the mother's symptoms have subsided.

3 Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that caution the nurse to focus interventions on the client's safety. The nurse should advise the client to get help the first few times she gets out of bed. Option 1 is not a helpful action in this situation and would not relieve the symptoms. Option 2 requires a health care provider's prescription. Option 4 is unnecessary.

A nurse is monitoring the client for signs of postpartum depression. Which would indicate the need for further assessment related to this form of depression? 1. The client is caring for the infant in a loving manner. 2. The client demonstrates an interest in the surroundings. 3. The client constantly complains of tiredness and fatigue. 4. The client looks forward to visits from the father of the newborn.

3 Postpartum depression is not the normal depression that many new mothers experience from time to time. The client experiencing depression shows less interest in her surroundings and a loss of her usual emotional response toward the family. The client also is unable to show pleasure or love and may have intense feelings of unworthiness, guilt, and shame. The client often expresses a sense of loss of self. Generalized fatigue, complaints of ill health and difficulty in concentrating also are present. The client would have little interest in food and experience sleep disturbances.

A postpartum care unit nurse is reviewing the records of 4 new mothers admitted to the unit. The nurse determines that which mother would be least likely at risk for developing a puerperal infection? 1. A mother who had ten vaginal exams during labor 2. A mother with a history of previous puerperal infections 3. A mother who gave birth vaginally to a 3200 gram infant 4. A mother who experienced prolonged rupture of the membranes

3 Risk factors associated for puerperal infection include a history of previous puerperal infections, cesarean births, trauma, prolonged rupture of the membranes, prolonged labor, multiple vaginal exams, and retained placental fragments.

The rubella vaccine is prescribed to be administered to a client 2 days after delivery of her child. The nurse preparing to administer the vaccine develops a list of the potential risks associated with this vaccine. The nurse reviews the list with the client and cautions the client to avoid which situation? 1. Sunlight for 3 days 2. Scratching the injection site 3. Pregnancy for 2 to 3 months after the vaccination 4. Sexual intercourse for 2 to 3 months after the vaccination

3 Rubella vaccine is a live attenuated virus that evokes an antibody response, which provides immunity for 15 years. Because rubella is a live vaccine, it will act as the virus and is potentially teratogenic in the organogenesis phase of fetal development. The client needs to be informed about the potential effects of this vaccine and the need to avoid becoming pregnant for 2 to 3 months after receiving the vaccine. Sunlight has no effect on the client who is vaccinated. The vaccine may cause local or systemic reactions, but all of these are mild and short-lived. Abstinence from sexual intercourse is not necessary unless another form of effective contraception is not being used.

The nurse is monitoring a postpartum client in the fourth stage of labor. Which finding, if noted by the nurse, would indicate a complication related to a laceration of the birth canal? 1. Presence of dark red lochia 2. Palpation of the uterus as a firm contracted ball 3. The saturation of more than one peripad per hour 4. Palpation of the fundus at the level of the umbilicus

3 Saturation of more than one peripad per hour is considered excessive even in the early postpartum period. In the first 24 hours after birth, the uterus will feel like a firmly contracted ball, roughly the size of a large grapefruit. One easily can locate the uterus at the level of the umbilicus. Lochia should be dark red and moderate in amount.

A client with known cardiac disease has been admitted to the postpartum care unit after an uneventful delivery. The unit nurse instructs the client to use the call button for assistance whenever she needs to get out of bed or wishes to care for her infant. Which postpartum complication is the nurse most concerned about for this client? 1. Postpartum infection 2. Maternal attachment 3. Maternal overexertion 4. Postpartum newborn-mother bonding

3 The immediate postpartum period is associated with increased risks for the cardiac client. Hormonal changes and fluid shifts from extravascular tissues to the circulatory system cause additional stress on cardiac functioning. Although options 1, 2, and 4 are appropriate nursing concerns during the postpartum period, the primary concern for the cardiac client is to maintain a safe environment because of the potential for cardiac compromise.

On assessment of a client who is 30 minutes into the fourth stage of labor, the nurse finds the client's perineal pad saturated in blood and blood soaked into the bed linen under the client's buttocks. Which is the nurse's initial action? 1. Call the health care provider. 2. Assess the client's vital signs. 3. Gently message the uterine fundus. 4. Administer a 300-mL bolus of a 20 units/L oxytocin (Pitocin) solution.

3 The most frequent cause of excessive bleeding after childbirth is uterine atony. A major intervention to restore adequate tone is stimulation of the uterine muscle via gently massaging the uterine fundus. Options 1, 2, and 4 may be necessary but they are not initial actions. The initial action is to alleviate the problem. Additionally a health care provider's prescription is needed to administer a medication.

The discharge nurse is discussing mastitis with a postpartum client. Which statement made by the client indicates a need for further instruction? 1. "If I develop a hot, reddened, triangle-shaped area on my breast, I should contact my health care provider." 2. "Antibiotics, rest, warm compresses, and adequate fluid intake are all important for the treatment of mastitis." 3. "If I develop a fever, chills, or body aches at any time after discharge, I should stop breast-feeding immediately." 4. "I may develop mastitis if I wear underwire bras, experience excessive fatigue, or suddenly decrease the number of feedings."

3 The mother should not discontinue breast-feeding even if mastitis occurs. Mastitis, a breast infection, is best characterized by a sudden onset of flulike symptoms, localized breast pain and tenderness, and a hot, reddened area on the breast that often resembles the shape of a pie wedge. Treatment usually includes antibiotics, but the mother should be instructed to feed the baby or pump frequently to adequately empty the affected breast.

The nurse is assigned to care for a client who has chosen to formula-feed her infant. The nurse should plan to provide which instruction to the client? 1. Apply a heating pad to breasts for comfort. 2. Wear a breast shield to correct nipple inversion. 3. Wear a supportive brassiere continuously for 72 hours. 4. Use the manual breast pump provided to express milk.

3 Wearing a supportive brassiere continuously for 72 hours postpartum will minimize breast engorgement. Any stimulation of the breasts (expression of milk, infant sucking) or increase in circulation (heating pad) will increase milk production or cause the blood vessels and lymphatics to engorge. Correction of nipple inversion will not be necessary if the mother chooses not to breast-feed her infant.

The student nurse asks the clinical instructor about changes in normal elimination patterns of infants. Which response given by the clinical instructor is most appropriate? 1 "Formula-fed infants pass more stools every day than breastfed infants." 2 "Formula-fed infants' stools are less offensive than breastfed infants' stools." 3 "Breastfed infants should pass stools three times a day for the first few weeks." 4 "The stools of formula-fed infants should resemble mustard mixed with cottage cheese."

3 - "Breastfed infants should pass stools three times a day for the first few weeks." pg 595 - Breastfed infants should pass stools three times a day for the first few weeks. Any deviation from this indicates problems related to stooling. Formula-fed infants have fewer stools than breastfed infants. The formula-fed infants may have as few as one stool every other day after the first few weeks. The odor of the stools of formula-fed infants is more offensive than that of infants who are breastfed. The stools of breastfed infants are looser and resemble mustard mixed with cottage cheese.

The nurse is educating the parents of a newborn about the use of the bulb syringe. Which statement from the parents indicates effective learning about the bulb syringe? 1 "It is used in the baby to prevent defecation from the anal opening." 2 "It is used in the baby to reduce the temperature during hypothermia." 3 "It is used in the baby to prevent suffocation and clear airway obstruction." 4 "It is used in the baby to avoid heat loss due to evaporation and convection."

3 - "It is used in the baby to prevent suffocation and clear airway obstruction." pg 571 - The bulb syringe is used to prevent suffocation and clear airway obstruction of newborns, and hence, it prevents aspiration. If the newborn's anal opening prevents defecation, it leads to severe gastrointestinal abnormalities. The bulb syringe is not used to reduce the newborn's temperature during hypothermia. It is also not used to avoid heat loss from the newborn due to evaporation and convection. Heat loss from the newborn is avoided by using warm water for bathing, drying the newborn carefully, and avoiding exposing the newborn to drafts.

The nurse is teaching a student nurse about stool patterns of a breastfed infant. What statement made by the student nurse indicates the need for further teaching? 1 "Watery stools are considered normal." 2 "Green-colored stools are considered diarrhea." 3 "Stool would have a water ring in normal conditions." 4 "Stool frequency may be three times a day in normal condition."

3 - "Stool would have a water ring in normal conditions." pg 602 - Stools in a normal breastfed neonate will not have a water ring. Presence of a water ring in a stool indicates that the infant has diarrhea. Watery stools are normal findings of breastfed neonates. Green-colored stool indicates diarrhea. A breastfed neonate has a stool frequency of more than three times per day.

The nurse auscultates a neonate in resting position and hears a murmur. What further assessments should the nurse make to know if the infant has any cardiac defects? 1 Measure the circumference of the head 2 Assess movements of the lower extremities 3 Assess blood pressure (BP) in all four extremities 4 Monitor blood pressure (BP) in the upper extremities

3 - Assess blood pressure (BP) in all four extremities pg 557 - When murmurs are heard, the nurse should check the neonates' BP from all four extremities to rule out congenital heart diseases. Circumference of the head is measured to detect head-related complications, such as microcephaly and hydrocephaly. However, it is unrelated to congenital heart disease. Assessing the body movements would correlate more with the muscular activity of the neonate but not with cardiac activity.

The nurse hands over a newborn to the mother after phototherapy. After some time the mother reports that the child has loose stools. What would account for the infant's loose stools? 1 Administration of glucose water 2 Administration of infant formula 3 Bilirubin-induced gastric motility 4 Decreased body fluids in the body

3 - Bilirubin-induced gastric motility pg 579 - The breakdown of bilirubin increases gastric motility, which results in loose stools that can cause skin excoriation and breakdown. The infant's buttocks must be cleaned after each stool to maintain skin integrity. Loose stools are not caused by decreased body fluids; instead, the loose stools lead to decreased body fluids and dehydration in the body. Administration of glucose water or plain water perpetuates enterohepatic circulation but delays the bilirubin excretion from the body. Administration of infant formula after phototherapy is highly beneficial to the infant to combat dehydration resulting from fluid loss from the body. However, it does not lead to loose stools.

A mother expresses fear about changing her infant's diaper after he is circumcised. What does the woman need to be taught to take care of the infant when she gets home? 1 Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours 2 Wash off the yellow exudate that forms on the glans at least once every day to prevent infection 3 Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change 4 Apply constant, firm pressure by squeezing the penis with the fingers for at least 5 minutes if bleeding occurs

3 - Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change pg 587 - With each diaper change, the penis should be washed off with warm water, not prepackaged diaper wipes, to remove any urine or feces. If bleeding occurs, the nurse should apply gentle pressure to the site of the bleeding with a sterile gauze square. This action is appropriate when caring for an infant who has had a circumcision. Yellow exudate covers the glans penis in 24 hours after the circumcision. This is part of normal healing and not an infective process. The exudate should not be removed.

The mother of a newborn reports that the baby scratches himself with his long nails. What would the nurse suggest to the mother? Select all that apply. 1 Clip the baby's nails every day 2 Cut the nails while the baby is playing 3 Cut the nails while the baby is sleeping 4 Cut the nails while breastfeeding the baby 5 Cover the baby's hands with loose-fitting mitts

3 - Cut the nails while the baby is sleeping 5 - Cover the baby's hands with loose-fitting mitts pg 601 - The nurse suggests that the mother cut the baby's nails when the baby is sleeping. Covering the hands of the baby with loose-fitting mitts would protect the baby from scratching himself. Since the nails do not grow very fast, it is not necessary to cut them daily. The infant's nails should not be cut while playing, because it may disturb the movement of extremities and could cause injuries to the fingers. Cutting the nails while the baby is breastfeeding is also not recommended, because it disturbs the feeding infant.

The nurse is assessing a newborn undergoing phototherapy. What changes would the nurse likely notice in the newborn during the process? 1 Increased urinary output 2 Increased blood pressure 3 Increased stool frequency 4 Increased skin discoloration

3 - Increased stool frequency pg 577 - Phototherapy is performed in the newborn with increased bilirubin levels (jaundice). During this process excess bilirubin is eliminated through stools and increases the gastric motility. Therefore the nurse may observe an increase in stool frequency in a newborn. Urinary output may be reduced or may remain unaltered as a result of hydration, but it does not increase during the phototherapy session. An increase in blood pressure in the newborn is a rare observation and is not associated with phototherapy. During phototherapy the yellow discoloration of the skin caused by jaundice is reduced, not increased.

The nurse is assessing a preterm infant with no muscle mass. The primary health care provider instructs the nurse to administer vitamin K to the infant. What route of administration does the nurse choose for diluted vitamin K? 1 Oral route over 10 to 15 minutes 2 Ophthalmic route over 10 to 15 minutes 3 Intravenous (IV) route over 10 to 15 minutes 4 Intramuscular (IM) route over 10 to 15 minutes

3 - Intravenous (IV) route over 10 to 15 minutes pg 573 - Vitamin K is typically administered through the IM route for infants. Because the infant is preterm with no muscle mass, vitamin K is administered in a diluted form through the IV route over 10 to 15 minutes. Because infants have underdeveloped digestive systems, vitamin K is not administered orally. The ophthalmic route is not advised, because vitamin K is not administered to treat eye disorders. Vitamin K is not administered via the IM route in the case of a preterm infant with no muscle mass.

Which statement provides helpful and accurate nursing advice concerning bathing the newborn? Select all that apply. 1 Bathe immediately after feeding while baby is calm and relaxed. 2 Only plain warm water can be used to preserve the skin's acid mantle. 3 Powders are not recommended because the infant can inhale powder. 4 Newborns should be bathed every day, for the bonding as well as the cleaning. 5 Tub baths may be given before the infant's umbilical cord falls off and the umbilicus is healed.

3 - Powders are not recommended because the infant can inhale powder. 5 - Tub baths may be given before the infant's umbilical cord falls off and the umbilicus is healed. pg 598/599 - Tub baths may be given as soon as an infant's temperature has stabilized. Powder is not recommended because of the risk of inhalation. If a parent chooses to use baby powder, it should never be sprinkled directly onto the baby's skin. The parent can apply a small amount of powder to his or her own hand and then apply to the infant. Newborns do not need a bath every day, even if the parents enjoy it. The diaper area and creases under the arms and neck need more attention. Unscented mild soap is appropriate to use to wash the infant. Do not bathe immediately after a feeding period because the increased handling may cause regurgitation.

The nurse is caring for a 3-week-old infant. Upon assessment the nurse finds that the infant has impaired acoustic nerve functioning. What does the nurse infer from this finding about the infant's clinical condition? 1 The infant has cataracts in the eye. 2 The infant has regular laryngospasms. 3 The infant has reduced hearing abilities. 4 The infant has persisting petechiae on the skin.

3 - The infant has reduced hearing abilities. pg 582 - The hearing function of an infant is assessed by examining acoustic nerve stimulations. This can be performed with the evoked otoacoustic emissions (EOAE) test and auditory brainstem response (ABR) test. Cataracts are usually observed in an infant with elevated galactose levels. Impaired acoustic nerve stimulation does not indicate laryngospasms. Laryngospasms in an infant signifies lowered calcium levels. Persisting petechiae indicate an underlying hemorrhage disorder in an infant and are not related to the acoustic nerve stimulations.

Upon assessing the CRIES neonatal postoperative pain scale findings, the nurse concludes that the infant is experiencing severe pain. What finding made the nurse conclude this? 1 The infant wakes up frequently. 2 The infant's skin has a pink complexion. 3 The infant requires 40% oxygen support. 4 The infant's heart rate was 110 beats/min.

3 - The infant requires 40% oxygen support. pg 590 - According to the CRIES scale, the infant is experiencing severe pain when he or she requires more than 30% oxygen support to maintain normal functioning. The normal heart rate of an infant is 110 beats/min. The heart rate increases when the infant cries. The infant waking frequently does not necessarily indicate severe pain. A pink complexion is a normal indication, so a pink complexion does not cause the nurse to conclude that the infant is in severe pain.

During assessment, the nurse finds that the heart rate of a neonate is 110 beats/min and respiratory rates vary from 35 to 40 breaths/min. The nurse also finds that the neonate has a pink complexion. What conclusion regarding the Apgar score would the nurse make from these findings? 1 The neonate has hypothermia. 2 The neonate had stress during birth. 3 The neonate exhibits normal findings. 4 The neonate has an infected umbilicus

3 - The neonate exhibits normal findings. pg 555 - An Apgar score of 7 to 10 indicates that the baby is normal with less difficulty adjusting to extrauterine life. Observations such as a pink complexion and a heart rate of more than 100 beats/min indicate that the baby is normal. Therefore the nurse would rate the child a score of 7 to 10. An Apgar score of 4 to 6 indicates hypothermia, because the infant shows moderate difficulty in adapting to extrauterine life. Scores of 0 to 3 indicate severe stress during birth and may show alterations in heart rate and respiration. Infection of the umbilicus may occur because of difficulty in adapting to extrauterine life and is not a normal finding in a child.

During assessment, the nurse finds that the heart rate of a neonate is 110 beats/min and respiratory rates vary from 35 to 40 breaths/min. The nurse also finds that the neonate has a pink complexion. What conclusion regarding the Apgar score would the nurse make from these findings? 1 The neonate has hypothermia. 2 The neonate had stress during birth. 3 The neonate exhibits normal findings. 4 The neonate has an infected umbilicus.

3 - The neonate exhibits normal findings. pg 555 - An Apgar score of 7 to 10 indicates that the baby is normal with less difficulty adjusting to extrauterine life. Observations such as a pink complexion and a heart rate of more than 100 beats/min indicate that the baby is normal. Therefore the nurse would rate the child a score of 7 to 10. An Apgar score of 4 to 6 indicates hypothermia, because the infant shows moderate difficulty in adapting to extrauterine life. Scores of 0 to 3 indicate severe stress during birth and may show alterations in heart rate and respiration. Infection of the umbilicus may occur because of difficulty in adapting to extrauterine life and is not a normal finding in a child.

The primary health care provider instructs the nurse to administer hepatitis B immune globulin (HBIG) to a neonate within 12 hours of birth. The neonate was born to a mother whose HBsAg status is unknown. What does the nurse infer from such instruction? 1 Polycythemia is present. 2 The mother weighed 65 kg at birth. 3 The neonate weighs 2000 g or less. 4 Maternal gestational hypertension is present.

3 - The neonate weighs 2000 g or less. pg 586 - HBIG must be administered within 12 hours of birth to an infant born to a mother whose HBsAg status is unknown if the infant weighs less than or equal to 2000 g. Administration of HBIG is not prescribed for polycythemia. The mother's weight is not a factor to be considered for administration of HBIG to the newborn, because it has no effect on the vaccination. Similarly, gestational hypertension of the mother does not affect the administration of HBIG to the newborn.

The primary health care provider instructs the nurse to give a hepatitis B (HepB) vaccine to a newborn. How should the nurse administer the vaccine? Select all that apply. 1 Through the deltoid muscle 2 Via the dorsogluteal muscle 3 Using the vastus lateralis muscle 4 By inserting the needle at a 60-degree angle 5 By inserting the needle at a 90-degree angle

3 - Using the vastus lateralis muscle 5 - By inserting the needle at a 90-degree angle pg 585 - The preferred injection site for a newborn is the vastus lateralis muscle in the thigh at a 90-degree angle. This is the best choice because this muscle has an adequate amount of muscle mass and fat. Administration of the hepatitis B (HepB) vaccine through the deltoid muscle is not recommended in infants, because this muscle has an inadequate amount of muscle for intramuscular (IM) administration. The dorsogluteal muscle is very small, poorly developed, and dangerously close to the sciatic nerve, which occupies a proportionately larger area in infants than in older children. Therefore it is not recommended as an injection site in newborns. The administration of the HepB vaccine is done by inserting the needle at a 90-degree angle, not at a 60-degree angle.

A client who is a gravida III, para III had a cesarean section 1 day ago. She is being treated prophylactically for endometritis. She is complaining of abdominal cramping at a level of 6 on pain level scale of 1 to 10 (with 10 being the greatest amount of pain) and fears having her first bowel movement. These medications are prescribed and due now. Based on priority, in which order should the nurse administer the medications? Arrange the medications in the order that they should be administered. All options must be used. Drag the text in the left column to the correct order in the right column. Prenatal vitamin 1 tablet orally daily 1 Docusate sodium (Colace) 100 mg orally 2 Ketorolac (Toradol) 30 mg by intravenous push over 3 minutes 3 Ampicillin sodium (Ampicillin) 1 g intravenous (IV) piggyback over 60 minutes

3, 4, 2, 1 The client is complaining of abdominal cramping, which is the priority and should be treated first; an IV route (ketorolac) is used because it will alleviate the pain rapidly. The risk of infection is greater than the need for a stool softener or a multivitamin; therefore, the IV antibiotic is administered next. The client who has not had her first bowel movement and is afraid to do so is the next priority; therefore, the docusate sodium would be administered next. The multivitamin requires daily administration and works over time to assist in replenishing the nutrients lost during blood loss associated with the surgery; this would be administered last.

A nurse is caring for a PP woman who has received epidural anesthesia and is monitoring the woman for the presence of a vulva hematoma. Which of the following assessment findings would best indicate the presence of a hematoma? Complaints of a tearing sensation Complaints of intense pain Changes in vital signs Signs of heavy bruising

3. Because the woman has had epidural anesthesia and is anesthetized, she cannot feel pain, pressure, or a tearing sensation. Changes in vitals indicate hypovolemia in the anesthetized PP woman with vulvar hematoma. Heavy bruising may be visualized, but vital sign changes indicate hematoma caused by blood collection in the perineal tissues.

A client is complaining of painful contractions, or afterpains, on postpartum day 2. Which of the following conditions could increase the severity of afterpains? Bottle-feeding Diabetes Multiple gestation Primiparity

3. Multiple gestation, breastfeeding, multiparity, and conditions that cause overdistention of the uterus will increase the intensity of after-pains. Bottle-feeding and diabetes aren't directly associated with increasing severity of afterpains unless the client has delivered a macrosomic infant.

A new mother received epidural anesthesia during labor and had a forceps delivery after pushing 2 hours. At 6 hours PP, her systolic blood pressure has dropped 20 points, her diastolic BP has dropped 10 points, and her pulse is 120 beats per minute. The client is anxious and restless. On further assessment, a vulvar hematoma is verified. After notifying the health care provider, the nurse immediately plans to: Monitor fundal height Apply perineal pressure Prepare the client for surgery. Reassure the client

3. The use of an epidural, prolonged second stage labor and forceps delivery are predisposing factors for hematoma formation, and a collection of up to 500 ml of blood can occur in the vaginal area. Although the other options may be implemented, the immediate action would be to prepare the client for surgery to stop the bleeding.

Which of the following circumstances is most likely to cause uterine atony and lead to PP hemorrhage? Hypertension Cervical and vaginal tears Urine retention Endometritis

3. Urine retention causes a distended bladder to displace the uterus above the umbilicus and to the side, which prevents the uterus from contracting. The uterus needs to remain contracted if bleeding is to stay within normal limits. Cervical and vaginal tears can cause PP hemorrhage but are less common occurrences in the PP period.

On the second postpartum day, a client complains of burning on urination, urgency, and frequency of urination. A urinalysis indicates the presence of a urinary tract infection. The nurse instructs the client regarding measures to take for the treatment of the infection. Which client statement indicates to the nurse the need for further instruction? 1. "I need to urinate frequently throughout the day." 2. "The prescribed medication must be taken until it is finished." 3. "My fluid intake should be increased to at least 3000 mL daily." 4. "Foods and fluids that will increase urine alkalinity should be consumed."

4 A client with a urinary tract infection must be encouraged to take the medication for the entire time it is prescribed. The client should also be instructed to drink at least 3000 mL of fluid each day to flush the infection from the bladder and to urinate frequently throughout the day. Foods and fluids that acidify the urine need to be encouraged.

The nurse is teaching a new mother how to care for her newborn. The nurse notes that the client is very fearful and reluctant to handle the newborn and notes that this is the client's first child. Which nursing intervention is least appropriate in assisting the promotion of mother-infant interaction and bonding? 1. Accepting the client's feelings 2. Acknowledging the client's apprehension 3. Assisting the client with giving the baths to allow her to become more at ease 4. Leaving the infant with the client so that she will be required to provide the care

4 A client with no experience of handling infants may be fearful and reluctant to handle her newborn or to take on physical care on her own. Leaving the infant with the mother so that she will be required to provide the care will produce additional apprehension. Acceptance of her feelings and acknowledgment of the apprehension can help an unsure mother begin to participate in caring for her newborn. Assistance will help the client become more at ease.

A postpartum unit nurse is preparing to care for a client who has just delivered a healthy newborn. In the immediate postpartum period what is the recommended frequency for the nurse to assess the client's vital signs? 1. Every hour for the first 2 hours and then every 4 hours 2. Every 30 minutes during the first hour and then every hour for the next 2 hours 3. Every 5 minutes for the first 30 minutes and then every hour for the next 4 hours 4. Every 15 minutes during the first hour and then every 30 minutes for the next 2 hours

4 During the immediate postpartum period, the nurse takes vital signs every 15 minutes in the first hour after birth, every 30 minutes for the next 2 hours, and every hour for the next 2 to 6 hours. The nurse monitors vital signs thereafter every 4 hours for 24 hours and every 8 to 12 hours for the remainder of the hospital stay.

A nurse has just received an intershift report. After reviewing the client assignment and the appropriate medical records, the nurse determines that which client is most at risk for developing postdelivery endometritis? 1. A primigravida with a normal spontaneous vaginal delivery 2. A gravida II who delivered vaginally following an 18-hour labor 3. A client experiencing an elective cesarean delivery at 38 weeks' gestation 4. An adolescent experiencing an emergency cesarean delivery for fetal distress

4 Endometritis is an acute infection of the uterine mucous lining immediately after delivery and is still a leading cause of mortality for childbearing women in the United States. Cesarean delivery is the primary risk factor for uterine infection, especially after emergency procedures. Other risk factors include prolonged rupture of membranes, multiple vaginal examinations, and an excessive length of labor. The other options do not describe the client most at risk to develop endometritis following delivery.

On the second postpartum day, a woman complains of burning on urination, urgency, and frequency of urination. A urinalysis is done, and the results indicate the presence of a urinary tract infection. The nurse instructs the new mother regarding measures to take for treatment of the infection. Which statement, if made by the mother, would indicate a need for further instructions? 1. "I need to urinate frequently throughout the day." 2. "The prescribed medication must be taken until it is finished." 3. "My fluid intake should be increased to at least 3000 mL daily." 4. "Foods and fluids that will increase urine alkalinity should be consumed."

4 Foods and fluids that acidify, not alkalinize the urine should be encouraged. The woman should be encouraged to urinate frequently throughout the day, instructed to take the medication for the entire time it is prescribed, and encouraged to drink at least 3000 mL of fluid each day to flush the infection from the bladder.

Which nursing intervention would be most appropriate for a postpartum client with a diagnosis of endometritis to facilitate participation in newborn care? 1. Limit fluid intake. 2. Maintain the client in a supine position. 3. Ask family members to care for the newborn. 4. Encourage the client to take pain medication as prescribed.

4 Nursing responsibilities for the care of the client with endometritis include maintaining adequate hydration (3000 to 4000 mL/day), bed rest in Fowler's position to facilitate drainage and lessen congestion, providing appropriate analgesia to lessen the pain, and administering antibiotics as prescribed. If the client's pain is relieved, she will be more likely to participate in newborn care. Asking family members to care for the newborn will not facilitate client participation in newborn care.

The nurse caring for a client with a diagnosis of subinvolution should understand that which is a primary cause of this diagnosis? 1. Afterpains 2. Increased estrogen levels 3. Increased progesterone levels 4. Retained placental fragments from delivery

4 Retained placental fragments and infections are the primary causes of subinvolution. When either of these processes is present, the uterus has difficulty contracting. The presence of afterpains is an expected finding following delivery. Options 2 and 3 are not causes of subinvolution.

The nursing instructor is reviewing the plan of care with a student regarding care of a postpartum client. The instructor asks the nursing student about the taking-in phase according to Rubin's phases of regeneration and the client behaviors that are most likely to occur during this phase. Which response made by the student indicates an understanding of this phase? 1. "The client would be independent." 2. "The client initiates activities on her own." 3. "The client participates in mothering tasks." 4. "The client is self-focused and talks to others about labor."

4 Rubin has identified three phases of regeneration during the postpartum period. The taking-in phase occurs in the first 3 days postpartum, and the taking-hold phase occurs between days 3 to 10. During the taking-in phase, the new mother is attempting to integrate her labor and birth experience. She tends to need sleep and feels fatigued, talks about labor, and is self-focused and dependent. In the taking-hold phase, the client is more active, independent, initiates activities, and partakes in mothering tasks. In the letting-go phase, the mother may grieve over the separation of the baby from part of her body.

The postpartum unit nurse has provided discharge instructions to a client planning to breast-feed her normal, healthy infant. Which statement by the client indicates an understanding of the instructions? 1. "If I experience any sweating during the night, I should call the health care provider." 2. "If I have uterine cramping while breast-feeding, I should contact the health care provider." 3. "If I'm still having bloody vaginal drainage in a week, I should contact the health care provider." 4. "If I notice any pain, redness, or swelling in my breasts, I should contact the health care provider."

4 Signs of infection include pain, redness, heat, and swelling of a localized area of the breast. If these symptoms occur, the client needs to contact the HCP. Options 1, 2, and 3 are normal changes that occur in the postpartum period.

The home care nurse's assignment is to visit a new mother at home 24 to 48 hours after discharge. What should the nurse expect to note in a healthy mother who is breast-feeding her newborn infant? 1. The mother has cracked nipples and feeds the infant with a supplemental bottle. 2. The mother complains of breast engorgement, and the infant demonstrates difficulty in latching onto the breast. 3. The mother is breast-feeding the infant with the infant's head turned toward her breast and the body flat in her arms; the mother has sore nipples, and the infant has a suck blister. 4. The mother is breast-feeding with the infant in a tummy-to-tummy position without signs of cracked nipples; the baby demonstrates bursts of sucking, followed by a pause and swallow.

4 The infant should be positioned completely facing the mother with head, neck, and spine aligned. Poor positioning increases the number of attempts for latching on. The infant's head turned toward the breast and the body flat in the mother's arms is incorrect because it demonstrates improper positioning. Breast engorgement, sore nipples, and cracked nipples are all complications that are the result of improper positioning.

The postpartum unit nurse has provided information regarding performing a sitz bath to a new mother after a vaginal delivery. The client demonstrates understanding of the purpose of the sitz bath by stating that the sitz bath will promote which action? 1. Numb the tissue. 2. Stimulate a bowel movement. 3. Reduce the edema and swelling. 4. Assist in healing and provide comfort.

4 Warm, moist heat is used after the first 24 hours after tissue trauma from a vaginal birth to provide comfort and promote healing and reduce the incidence of infection. This warm, moist heat is provided via a sitz bath. Ice is used in the first 24 hours to reduce edema and numb the tissue. Promoting a bowel movement is best achieved by ambulation.

The mother of a circumcised infant reports to the nurse that while she is cleaning her child's penis, he cries out loudly. What question does the nurse ask the patient to understand the reason behind this? 1 "Are you applying A&D ointment while cleaning?" 2 "Are you cleaning the penis with lukewarm water?" 3 "Are you applying fresh petrolatum while cleaning?" 4 "Are you cleaning with prepackaged commercial wipes?"

4 - "Are you cleaning with prepackaged commercial wipes?" pg 588 - Do not use prepackaged commercial baby wipes for cleaning the circumcised site because they can contain alcohol. Alcohol delays healing and also causes discomfort to the infant. The infant cries out loudly because of the discomfort. Washing the penis gently with lukewarm water is recommended to remove urine and feces. Fresh petrolatum is applied to reduce pain after each diaper change. The application of A&D ointment while cleaning is done to prevent the sticking of the penis to the discharge, as well as to increase the infant's comfort.

The nurse is educating a group of new mothers about the use of pacifiers for their infants. Which statement does the nurse include in the teaching? 1 "Pacifiers should be designed and prepared at home." 2 "Pacifiers should be reinserted once the infant falls asleep." 3 "Pacifiers should be coated with any type of sweet solution." 4 "Pacifiers should be constructed as one piece with a shield."

4 - "Pacifiers should be constructed as one piece with a shield." pg 598 - Pacifiers that are made of one piece and include a shield or flange large enough to prevent entry into the mouth with a handle can be used safely. Homemade pacifiers may not be perfectly designed and may pose danger to the infant because the entire object or a portion may lodge into the pharynx. The pacifiers should not be reinserted into the mouth of the infant once the infant falls asleep, because it may disturb the infant's sleep. Pacifiers should not be coated with any type of sweet solution.

The nurse is assessing a neonate with hydrocephaly. What observation reported by the nurse would be consistent with the neonate's condition? 1 A body weight of 7 pounds 2 A heart rate 120 beats/min 3 A head-to-heel length of 55 cm 4 A head circumference greater than chest circumference

4 - A head circumference greater than chest circumference pg 562 - Hydrocephaly is a condition where fluids accumulate around the neonate's brain. Hydrocephaly is confirmed when the neonate's head circumference is 4.5 cm greater than the chest circumference. If a neonate has a body weight of 7 pounds, it is the normal weight of a newborn and does not indicate any abnormalities. A neonatal heart rate with 120 beats/min indicates that the newborn is healthy. A head-to-heel length of 55 cm is the normal body length of any newborn. This factor does not lead to hydrocephaly.

The student nurse is asked to distinguish cutaneous jaundice from normal skin color of a neonate. What will the student nurse do to differentiate them? 1 Evaluate the size of the nipples 2 Measure the circumference of the head 3 Observe the symmetry of lip movement 4 Apply pressure on the forehead with a finger

4 - Apply pressure on the forehead with a finger pg 577 - Distinction of cutaneous jaundice from normal skin color can be done by applying pressure on the forehead, nose, and sternum. The pressure on all these parts of the body can be applied with the finger for several seconds to empty all the capillaries in that spot. If jaundice is present, the blanched area will appear yellow before the capillaries refill. Nipple size can be evaluated to ensure the prominence of nipples. Symmetry of lip movement should be observed to detect seventh cranial nerve paralysis. Measuring the circumference of the head is done to determine the microcephaly or hydrocephaly.

The nurse must administer erythromycin ophthalmic ointment to a newborn after birth. What should the nurse do? 1 Apply directly over the cornea 2 Flush eyes 10 minutes after instillation to reduce irritation 3 Instill within 15 minutes of birth for maximum effectiveness 4 Cleanse eyes from inner to outer canthus before administration

4 - Cleanse eyes from inner to outer canthus before administration pg 572 - The newborn's eyes should be cleansed from the inner to the outer canthus before the administration of erythromycin ointment. Instillation of the ointment can be delayed for up to 1 hour to facilitate eye-to-eye contact between the newborn and parents, an activity that fosters bonding and attachment, especially for fathers. Erythromycin should be applied into the conjunctival sac to avoid accidental injury to the eye. The eyes should not be flushed after instillation of the erythromycin.

B (The Ortolani maneuver is a technique for checking hip integrity. Unequal movement suggests that the hip is dislocated. The physician should be notified.)

An examiner who discovers unequal movement or uneven gluteal skin folds during the Ortolani maneuver would then: a. Tell the parents that one leg may be longer than the other, but they will equal out by the time the infant is walking. b. Alert the physician that the infant has a dislocated hip. c. Inform the parents and physician that molding has not taken place. d. Suggest that, if the condition does not change, surgery to correct vision problems may be needed.

The nurse observes a tissue injury in a newborn caused during birth. The nurse blanches the skin and finds no change in the affected area. What type of injury does the baby have? 1 Skin rash on the face 2 Edema in the buttocks 3 Discoloration in the neck 4 Ecchymosis on the trunk

4 - Ecchymosis on the trunk pg 576 - When the nurse notices an injury in the newborn, the nurse blanches the skin to verify the type of changes that are exhibited. If the newborn has ecchymosis or petechiae, no changes will be observed from the blanching. This is because extravasated blood remains within the tissues when infants have ecchymosis. A skin rash or discoloration of the neck may change color when blanched. Edema is swelling caused by the force applied during the birth process. The nurse would not need to blanch the edematous skin, because it is easily observed and noticed.

The nurse gives a newborn an Apgar score of 4. What condition observed in the neonate would be consistent with the score? 1 Clear eyes 2 Acrocyanosis 3 Flexed posture 4 Heart rate of 70 beats/min

4 - Heart rate of 70 beats/min pg 555 - The Apgar score of 4 indicates that the neonate has difficulty adapting to the extrauterine environment. A heart rate of 70 beats/min is not a normal finding and can be consistent with the condition. Observations such as clear eyes, acrocyanosis, and flexed posture in the neonate are normal findings and suggest an Apgar score of 7 to 10. However, these findings are not consistent with the low Apgar score of 4.

The nurse is assessing an infant with a body weight of 2500 g. Two days after delivery the blood report of the infant's mother confirms the presence of hepatitis B. What medication does the primary health care provider instruct the nurse to administer to the infant? 1 Intravenous (IV) hepatitis B vaccine 2 Intramuscular (IM) hepatitis B vaccine 3 Intravenous (IV) hepatitis B immune globulin (HBIG) 4 Intramuscular (IM) hepatitis B immune globulin (HBIG)

4 - Intramuscular (IM) hepatitis B immune globulin (HBIG) pg 585 - A dose of IM HBIG should be given to the infant whose mother's hepatitis B surface antigen's (HBsAg) status is determined to be positive. The vaccine is also given to infants who weigh 2000 g or more before 1 week of age. The hepatitis B vaccine and HBIG are not given through the IV route in infants because of their adverse effects. The IM hepatitis B vaccine is given to infants born to hepatitis B surface antigen (HBsAg)-negative mothers before being discharged from the hospital.

The nurse is assessing a breastfed newborn 1 hour after birth. The nurse identified that the glucose levels are less than 25 mg/dL and immediately reported it to the primary health care provider (PHP). What medication administration does the nurse expect the PHP to advise? 1 Cow's milk orally 2 Infant formula orally 3 Intravenous (IV) saline infusion 4 Intravenous (IV) dextrose infusion

4 - Intravenous (IV) dextrose infusion pg 580 - If the glucose levels are less than 25 mg/dL in the first 4 hours, or less than 35 mg/dL in the first 4 to 24 hours, it indicates hypoglycemia. All infants at risk for hypoglycemia should be fed within the first hour, with glucose testing performed 30 minutes after breastfeeding. If the glucose levels remain low despite feeding, IV dextrose is prescribed to the newborn. Cow's milk is generally not preferred for infants, because it may cause infections. Administration of infant formula is recommended in infants with hypocalcemia. IV saline infusion is not beneficial to hypoglycemic infants, because a saline infusion consists of plain salts and does not increase the glucose levels in the body.

A 3.8-kg infant was delivered vaginally at 39 weeks after a 30-minute second stage. There was a nuchal cord. After birth, the infant is noted to have petechiae over the face and upper back. Information given to the infant's parents should be based on what? 1 Petechiae usually occur with forceps delivery. 2 Petechiae result from increased blood volume. 3 Petechiae should always be further investigated. 4 Petechiae are benign if they disappear within 48 hours of birth.

4 - Petechiae are benign if they disappear within 48 hours of birth. pg 576 - Petechiae, or pinpoint hemorrhagic areas, acquired during birth may extend over the upper portion of the trunk and face. These lesions are benign if they disappear within 2 days of birth and no new lesions appear. Petechiae may result from decreased platelet formation. In this situation the presence of petechiae is most likely a soft-tissue injury resulting from the nuchal cord at birth. Unless they do not dissipate in 2 days, there is no reason to alarm the family. Petechiae usually occur with a breech presentation vaginal birth.

When placing a newborn under a radiant heat warmer to stabilize the temperature after birth, what should the nurse do? 1 Cover the probe with a nonreflective material 2 Place the thermistor probe on the left side of the chest 3 Recheck the temperature by periodically taking a rectal temperature 4 Prewarm the radiant heat warmer and place the undressed newborn under it

4 - Prewarm the radiant heat warmer and place the undressed newborn under it pg 579 - The radiant warmer should be prewarmed so the infant does not experience more cold stress. The thermistor probe should be placed on the upper abdomen away from the ribs. It should be covered with reflective material. Rectal temperatures should be avoided because rectal thermometers can perforate the intestine, and the temperature may remain normal until cold stress is advanced.

The nurse is assessing the body temperature of a neonate born 8 hours ago by placing the neonate on the mother's abdomen. The nurse finds that the neonate's body temperature is decreasing gradually. Based on these findings, the nurse concludes the mother's record to be normal. Which maternal condition is responsible for the neonate's decreasing body temperature? 1 The mother has undergone cesarean birth. 2 The mother has gestational hyperglycemia. 3 The mother has received Ringer's lactate solution. 4 The mother has been administered magnesium sulfate.

4 - The mother has been administered magnesium sulfate. pg 560 - The nurse places the neonate on the mother's abdomen to maintain thermoregulation. If the mother has been administered magnesium sulfate, the newborn may develop vasoconstriction. This reduces the newborn's ability to conserve heat. Although the birth was through cesarean section, the newborn's temperature should stabilize within 9 hours after the birth in extrauterine life. Neither gestational hyperglycemia nor Ringer's lactate solution would prevent thermoregulation between the neonate and the mother.

When weighing a newborn, what should the nurse do? 1 Leave its diaper on for comfort 2 Keep hand on the newborn's abdomen for safety 3 Place a sterile scale paper on the scale for infection control 4 Weigh the newborn at the same time each day for accuracy

4 - Weigh the newborn at the same time each day for accuracy pg 557 - The baby should be weighed without a diaper or clothes. Clean scale paper is acceptable; it does not need to be sterile. The nurse's hand should be above (not on) the abdomen for safety. Weighing a newborn at the same time each day allows for accurate weights.

The nurse is assessing a neonate who is administered vitamin K intramuscularly (IM). What changes in the neonate would the nurse primarily monitor to ensure safety? 1 Increased heart rate 2 Increased body moments 3 Pink coloration of the skin 4 Yellow discoloration of sclera

4 - Yellow discoloration of sclera pg 573 - After vitamin K is administered, neonates develop jaundice-like side effects. Therefore the nurse should look for a yellow discoloration in neonates who have been administered vitamin K. Increased heart rate is a very rare complication observed in neonates. It is primarily observed when a neonate cries, but not when vitamin K is administered IM. Increased body movements may indicate Down syndrome and are not adverse effects of vitamin K. Pink coloration of the skin is a normal finding in neonates and is not associated with jaundice-like effects.

Which of the following responses is most appropriate for a mother with diabetes who wants to breastfeed her infant but is concerned about the effects of breastfeeding on her health? Mothers with diabetes who breast-feed have a hard time controlling their insulin needs Mothers with diabetes shouldn't breastfeed because of potential complications Mothers with diabetes shouldn't breastfeed; insulin requirements are doubled. Mothers with diabetes may breastfeed; insulin requirements may decrease from breastfeeding.

4. Breastfeeding has an antidiabetogenic effect. Insulin needs are decreased because carbohydrates are used in milk production. Breastfeeding mothers are at a higher risk of hypoglycemia in the first PP days after birth because the glucose levels are lower. Mothers with diabetes should be encouraged to breastfeed.

A postpartum nurse is taking the vital signs of a woman who delivered a healthy newborn infant 4 hours ago. The nurse notes that the mother's temperature is 100.2*F. Which of the following actions would be most appropriate? Retake the temperature in 15 minutes Notify the physician Document the findings Increase hydration by encouraging oral fluids

4. The mother's temperature may be taken every 4 hours while she is awake. Temperatures up to 100.4 (38 C) in the first 24 hours after birth are often related to the dehydrating effects of labor. The most appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. Although the nurse would document the findings, the most appropriate action would be to increase the hydration.

A nurse in a PP unit is instructing a mother regarding lochia and the amount of expected lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never exceed the need for: One peripad per day Two peripads per day Three peripads per day Eight peripads per day

4. The normal amount of lochia may vary with the individual but should never exceed 4 to 8 peripads per day. The average number of peripads is 6 per day.

On the first PP night, a client requests that her baby be sent back to the nursery so she can get some sleep. The client is most likely in which of the following phases? Depression phase Letting-go phase Taking-hold phase Taking-in phase

4. The taking-in phase occurs in the first 24 hours after birth. The mother is concerned with her own needs and requires support from staff and relatives. The taking-hold phase occurs when the mother is ready to take responsibility for her care as well as the infants care. The letting-go phase begins several weeks later, when the mother incorporates the new infant into the family unit.

3.Maternal overexertion The immediate postpartum period is associated with increased risks for the cardiac client. Hormonal changes and fluid shifts from extravascular tissues to the circulatory system cause additional stress on cardiac functioning. Although options 1, 2, and 4 are appropriate nursing concerns during the postpartum period, the primary concern for the cardiac client is to maintain a safe environment because of the potential for cardiac compromise.

A client with known cardiac disease has been admitted to the postpartum care unit after an uneventful delivery. The unit nurse instructs the client to use the call button for assistance whenever she needs to get out of bed or wishes to care for her infant. Which postpartum complication is the nurse most concerned about for this client? 1.Postpartum infection 2.Maternal attachment 3.Maternal overexertion 4.Postpartum newborn-mother bonding

A ("Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him" is an accurate statement. Conduction is the loss of heat from the body surface to cooler surfaces, not air, in direct contact with the newborn. Evaporation is loss of heat that occurs when a liquid is converted into a vapor. In the newborn heat loss by evaporation occurs as a result of vaporization of moisture from the skin. Cold stress may occur from excessive heat loss, but this does not imply that the infant will become stressed if not bundled at all times. Furthermore, excessive bundling may result in a rise in the infant's temperature.)

A client is warm and asks for a fan in her room for her comfort. The nurse enters the room to assess the mother and her infant and finds the infant unwrapped in his crib with the fan blowing over him on "high." The nurse instructs the mother that the fan should not be directed toward the newborn and the newborn should be wrapped in a blanket. The mother asks why. The nurse's best response is: a. "Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him." b. "Your baby may lose heat by conduction, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him." c. "Your baby may lose heat by evaporation, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him." d. "Your baby will get cold stressed easily and needs to be bundled up at all times."

At 1 minute following birth, the newborn exhibited the following: heart rate of 155; loud, vigorous crying with active movement of all extremities; sneezing when nose is stimulated with a catheter; hands and feet bluish and cool to the touch. The Apgar score of this newborn should be recorded as________. Record your answer as a whole number.

Answer - 9 pg 555 - The newborn receives 2 points each for a heart rate over 100 beats/min, a vigorous cry, active movement, and sneezing as a response to nasal stimulation. The newborn receives 1 point for color because he exhibits acrocyanosis.

A (Bleeding may occur during a spontaneous vaginal delivery as a result of the pressure against the maternal bony pelvis. The soft, irreducible fullness does not pulsate or bulge when the infant cries. Low forceps and other difficult extractions may result in bleeding. However, cephalhematomas can also occur spontaneously. The swelling may appear unilaterally or bilaterally and is usually minimal or absent at birth. It increases over the first 2 to 3 days of life. Cephalhematomas disappear gradually over 2 to 3 weeks. A less common condition results in calcification of the hematoma, which may persist for months.)

A collection of blood between the skull bone and its periosteum is known as a cephalhematoma. To reassure the new parents whose infant develops such a soft bulge, it is important that the nurse be aware that this condition: a. May occur with spontaneous vaginal birth. b. Happens only as the result of a forceps or vacuum delivery. c. Is present immediately after birth. d. Will gradually absorb over the first few months of life.

C (Physiologic jaundice becomes visible when the serum bilirubin reaches a level of 5 mg/dL or greater, which occurs when the baby is approximately 3 days old. This finding is within normal limits for the newborn. Pathologic jaundice occurs during the first 24 hours of life. Pathologic jaundice is caused by blood incompatibilities, causing excessive destruction of erythrocytes, and must be investigated. Breast milk jaundice occurs in one third of breastfed infants at 2 weeks and is caused by an insufficient intake of fluids.)

A first-time dad is concerned that his 3-day-old daughter's skin looks "yellow." In the nurse's explanation of physiologic jaundice, what fact should be included? a. Physiologic jaundice occurs during the first 24 hours of life. b. Physiologic jaundice is caused by blood incompatibilities between the mother and infant blood types. c. The bilirubin levels of physiologic jaundice peak between the second and fourth days of life. d. This condition is also known as "breast milk jaundice."

A ("That's meconium, which is your baby's first stool. It's normal" is an accurate statement and the most appropriate response. Transitional stool is greenish brown to yellowish brown and usually appears by the third day after initiation of feeding. "That means your baby is bleeding internally" is not accurate. "Oh, don't worry about that. It's okay" is not an appropriate statement. It is belittling to the father and does not educate him about the normal stool patterns of his daughter.)

A first-time father is changing the diaper of his 1-day-old daughter. He asks the nurse, "What is this black, sticky stuff in her diaper?" The nurse's best response is: a. "That's meconium, which is your baby's first stool. It's normal." b. "That's transitional stool." c. "That means your baby is bleeding internally." d. "Oh, don't worry about that. It's okay."

C (Meconium stool is usually passed in the first 12 hours of life, and 99% of newborns have their first stool within 48 hours. If meconium is not passed by 48 hours, obstruction is suspected. Meconium stool is the first stool of the newborn and is made up of matter remaining in the intestines during intrauterine life. Meconium is dark and sticky.)

A meconium stool can be differentiated from a transitional stool in the newborn because the meconium stool is: a. Seen at age 3 days. b. The residue of a milk curd. c. Passed in the first 12 hours of life. d. Lighter in color and looser in consistency.

2."Mastitis can occur at any time during breast-feeding." -Mastitis is an infection of the lactating breasts and occurs most often during the second and third weeks after birth, although it may develop at any time during breast-feeding. Mastitis is more common in mothers nursing for the first time and usually affects one breast. A supportive bra will not cause mastitis; however, constriction of the breasts from a bra that is too tight may interfere with the emptying of all the ducts and may lead to infection.

A new mother is seen in a health care clinic 2 weeks after giving birth to a healthy newborn infant. The mother is complaining that she feels as though she has the flu and complains of fatigue and aching muscles. On further assessment the nurse notes a localized area of redness on the left breast, and the mother is diagnosed with mastitis. The mother asks the nurse about the condition. The nurse should make which response? 1."Mastitis usually involves both breasts." 2."Mastitis can occur at any time during breast-feeding." 3."Mastitis usually is caused by wearing a supportive bra." 4."Mastitis is most common for women who have breast-fed in the past."

A (Acrocyanosis, or the appearance of slightly cyanotic hands and feet, is caused by vasomotor instability, capillary stasis, and a high hemoglobin level. Acrocyanosis is normal and appears intermittently over the first 7 to 10 days. Erythema toxicum (also called erythema neonatorum) is a transient newborn rash that resembles flea bites. The harlequin sign is a benign, transient color change in newborns. Half of the body is pale, and the other half is ruddy or bluish red with a line of demarcation. Vernix caseosa is a cheeselike, whitish substance that serves as a protective covering.)

A new mother states that her infant must be cold because the baby's hands and feet are blue. The nurse explains that this is a common and temporary condition called: a. Acrocyanosis. b. Erythema neonatorum. c. Harlequin color. d. Vernix caseosa.

B (Loss of heat must be controlled to protect the infant from the metabolic and physiologic effects of cold stress, and that is the primary reason for placing a newborn under a radiant heat warmer. Cold stress results in an increased respiratory rate and vasoconstriction.)

A newborn is placed under a radiant heat warmer, and the nurse evaluates the infant's body temperature every hour. Maintaining the newborn's body temperature is important for preventing: a. Respiratory depression. b. Cold stress. c. Tachycardia. d. Vasoconstriction.

4.An adolescent experiencing an emergency cesarean delivery for fetal distress Endometritis is an acute infection of the uterine mucous lining immediately after delivery and is still a leading cause of mortality for childbearing women in the United States. Cesarean delivery is the primary risk factor for uterine infection, especially after emergency procedures. Other risk factors include prolonged rupture of membranes, multiple vaginal examinations, and an excessive length of labor. The other options do not describe the client most at risk to develop endometritis following delivery.

A nurse has just received an intershift report. After reviewing the client assignment and the appropriate medical records, the nurse determines that which client is most at risk for developing postdelivery endometritis? 1.A primigravida with a normal spontaneous vaginal delivery 2.A gravida II who delivered vaginally following an 18-hour labor 3.A client experiencing an elective cesarean delivery at 38 weeks' gestation 4.An adolescent experiencing an emergency cesarean delivery for fetal distress

1.Massaging the uterus 3.Assisting the woman to urinate 5.Checking for a distended bladder If the uterus is soft and spongy and is not firmly contracted, the initial nursing action is to massage the fundus gently until it is firm; this will express clots that may have accumulated in the uterus. If the uterus does not remain contracted as a result of massage, the problem may be a distended bladder, which lifts and displaces the uterus and prevents effective contraction of the uterine muscles. The nurse would then check for a distended bladder and assist the woman to urinate. Pushing on an uncontracted uterus could invert the uterus, potentially causing massive hemorrhage and rapid shock. Waiting for 1 hour without intervention could result in bleeding. The health care provider will need to be notified if uterine massage is not helpful. Pharmacological measures may be necessary to maintain firm contraction of the uterus. An abdominal hysterectomy may need to be performed for massive hemorrhage that is uncontrollable. The question presents no data indicating that hemorrhage is a problem. Additionally, the nurse would not schedule an operative procedure.

A nurse is assessing the fundus in a postpartum woman and notes that the uterus is soft and spongy and is not firmly contracted. The nurse should prepare to implement which interventions? Select all that apply. 1.Massaging the uterus 2.Pushing gently on the uterus 3.Assisting the woman to urinate 4.Rechecking the uterus in 1 hour 5.Checking for a distended bladder 6.Calling the delivery room to schedule an abdominal hysterectomy

2.Hemorrhage Because the placenta is implanted in the lower uterine segment, which does not contain the same intertwining musculature as the fundus of the uterus, this site is more prone to bleeding. The other options are not risks that are specifically related to placenta previa.

A nurse is caring for a client who has just delivered a newborn following a pregnancy with a placenta previa. When reviewing the plan of care, the nurse should prepare to monitor the client for which risk that is associated with placenta previa? 1.Infection 2.Hemorrhage 3.Chronic hypertension 4.Disseminated intravascular coagulation

2.An increased pulse rate of 88 to 102 beats/min During the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. A rising pulse is an early sign of excessive blood loss, because the heart pumps faster to compensate for reduced blood volume. The blood pressure will fall as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage.

A nurse is monitoring a new mother in the fourth stage of labor for signs of hemorrhage. Which indicates an early sign of excessive blood loss? 1.A temperature of 100.4º F 2.An increased pulse rate of 88 to 102 beats/min 3.A blood pressure change from 130/88 to 124/80 mm Hg 4.An increase in the respiratory rate from 18 to 22 breaths/min

1.Wear a supportive bra between feedings. 3.Feed the infant at least every 2 hours for 15 to 20 minutes on each side. 4.Apply moist heat to both breasts for about 20 minutes before a feeding. 5.Massage the breasts gently during a feeding, from the outer areas to the nipples. During breast engorgement, the client should be advised to feed the infant frequently, at least every 2 hours, for 15 to 20 minutes on each side. The infant will have an easier time latching on if the client softens her breast and expresses her milk before a feeding. Instruct the client to apply moist heat to both breasts for about 20 minutes before a feeding. This can be done in the shower or with warm wet towels. During a feeding, it is helpful to massage the breast gently from the outer area to the nipple. This helps stimulate the let-down and flow of milk. The client should also be instructed to wear a supportive bra between feedings.

A nurse visits a client at home who delivered a healthy newborn 2 days ago. The client is complaining of breast discomfort. The nurse notes that the client is experiencing breast engorgement. Which instructions should the nurse provide to the client regarding relief of the engorgement? Select all that apply. 1.Wear a supportive bra between feedings. 2.Avoid breast-feeding during the time of breast engorgement. 3.Feed the infant at least every 2 hours for 15 to 20 minutes on each side. 4.Apply moist heat to both breasts for about 20 minutes before a feeding. 5.Massage the breasts gently during a feeding, from the outer areas to the nipples.

D (The condition will resolve itself within a few hours. For this common condition of newborns, surfactant acts to keep the expanded alveoli partially open between respirations. In vaginal births, absorption of remaining lung fluid is accelerated by the process of labor and delivery. Remaining lung fluid will move into interstitial spaces and be absorbed by the circulatory and lymphatic systems. This is a particularly common condition for infants delivered by cesarean section. Surfactant is produced by the lungs, so aspiration is not a concern.)

A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago by cesarean section is found to have moist lung sounds. What is the best interpretation of these data? a. The nurse should notify the pediatrician stat for this emergency situation. b. The neonate must have aspirated surfactant. c. If this baby was born vaginally, it could indicate a pneumothorax. d. The lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth.

4.Hematuria, ecchymosis, and epistaxis The treatment for deep vein thrombosis is anticoagulant therapy. The nurse assesses for bleeding, which is an adverse effect of anticoagulants. This includes hematuria, ecchymosis, and epistaxis. Dysuria and vertigo are not associated specifically with bleeding

A postpartum client with deep vein thrombosis is being treated with anticoagulant therapy. The nurse understands that the client's response to treatment will be evaluated by regularly assessing the client for which symptoms? 1.Dysuria, ecchymosis, and vertigo 2.Epistaxis, hematuria, and dysuria 3.Hematuria, ecchymosis, and vertigo 4.Hematuria, ecchymosis, and epistaxis

D (A Mongolian spot is a bluish black area of pigmentation that may appear over any part of the exterior surface of the body. It is more commonly noted on the back and buttocks and most frequently is seen on infants whose ethnic origins are Mediterranean, Latin American, Asian, or African. Lanugo is the fine, downy hair seen on a term newborn. A vascular nevus, commonly called a strawberry mark, is a type of capillary hemangioma. A nevus flammeus, commonly called a port-wine stain, is most frequently found on the face.)

An African-American woman noticed some bruises on her newborn girl's buttocks. She asks the nurse who spanked her daughter. The nurse explains that these marks are called: a. Lanugo. b. Vascular nevi. c. Nevus flammeus. d. Mongolian spots.

4.Every 15 minutes during the first hour and then every 30 minutes for the next 2 hours During the immediate postpartum period, the nurse takes vital signs every 15 minutes in the first hour after birth, every 30 minutes for the next 2 hours, and every hour for the next 2 to 6 hours. The nurse monitors vital signs thereafter every 4 hours for 24 hours and every 8 to 12 hours for the remainder of the hospital stay.

A postpartum unit nurse is preparing to care for a client who has just delivered a healthy newborn. In the immediate postpartum period what is the recommended frequency for the nurse to assess the client's vital signs? 1.Every hour for the first 2 hours and then every 4 hours 2.Every 30 minutes during the first hour and then every hour for the next 2 hours 3.Every 5 minutes for the first 30 minutes and then every hour for the next 4 hours 4.Every 15 minutes during the first hour and then every 30 minutes for the next 2 hours

3.Breast-feed from the left breast and gently pump the right breast. n most cases, the mother can continue to breast-feed with both breasts. If the affected breast is too sore, the mother can pump the breast gently. Regular emptying of the breast is important to prevent abscess formation. If an abscess forms and ruptures into the ducts of the breast, breast-feeding will need to be discontinued and a pump should be used to empty the breast (but the milk should be discarded). Options 1, 2, and 4 are incorrect.

A postpartum woman with mastitis in the right breast complains that the breast is too sore for her to breast-feed her infant. The nurse should tell the client to implement which measure? 1.Pump both breasts and discard the milk. 2.Bottle-feed the infant on a temporary basis. 3.Breast-feed from the left breast and gently pump the right breast. 4.Stop breast-feeding from both breasts until this condition resolves.

2.Pregnancy needs to be avoided for 1 to 3 months. 3.The vaccine is administered by the subcutaneous route. 4.Exposure to immunosuppressed individuals needs to be avoided. 5.A hypersensitivity reaction can occur if the client has an allergy to eggs.

A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply. 1.Breast-feeding needs to be stopped for 3 months. 2.Pregnancy needs to be avoided for 1 to 3 months. 3.The vaccine is administered by the subcutaneous route. 4.Exposure to immunosuppressed individuals needs to be avoided. 5.A hypersensitivity reaction can occur if the client has an allergy to eggs. 6.The area of the injection needs to be covered with a sterile gauze for 1 week.

1."What can I do for you?" -When a loss or death occurs, the nurse should ensure that parents have been honestly told about the situation by their health care provider or others on the health care team. It is important for the nurse to be with the parents at this time and to use therapeutic communication techniques. The nurse must also consider cultural and religious practices and beliefs. The correct option provides a supportive, giving, and caring response. Options 2, 3, and 4 are blocks to communication and devalue the parents' feelings.

A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would further assist the family in their initial period of grief? 1."What can I do for you?" 2."Now you have an angel in heaven." 3."Don't worry, there is nothing you could have done to prevent this from happening." 4."We will see to it that you have an early discharge so that you don't have to be reminded of this experience."

B (The first period of reactivity is the first phase of transition and lasts up to 30 minutes after birth. The infant is highly alert during this phase. The transition period is the phase between intrauterine and extrauterine existence. There is no such phase as the organizational stage. The second period of reactivity occurs roughly between 4 and 8 hours after birth, after a period of prolonged sleep.)

A woman gave birth to a healthy 7-pound, 13-ounce infant girl. The nurse suggests that the woman place the infant to her breast within 15 minutes after birth. The nurse knows that breastfeeding is effective during the first 30 minutes after birth because this is the: a. Transition period. b. First period of reactivity. c. Organizational stage. d. Second period of reactivity.

2.Support the mother in her reaction to the newborn infant. Precipitous labor is labor that lasts 3 hours or less. Women who have experienced precipitous labor often describe feelings of disbelief that their labor progressed so rapidly. To assist the client to process what has happened, the best option is to support the client in her reaction to the newborn infant. Options 1, 3, and 4 do not acknowledge the client's feelings.

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn infant briefly with her fingertips. What should the nurse do to help the woman process the delivery? 1.Encourage the mother to breast-feed soon after birth. 2.Support the mother in her reaction to the newborn infant. 3.Tell the mother that it is important to hold the newborn infant. 4.Document a complete account of the mother's reaction on the birth record.

4."The only medications I will take are prenatal vitamins and stool softeners." -A hematoma is a localized collection of blood into the tissues of the reproductive sac after delivery. A vulvar hematoma is the most common type. The postoperative client will need an antibiotic because she is at increased risk for infection as a result of the break in skin integrity and collection of blood at the hematoma site. Stating that she will need only prenatal vitamins and stool softeners indicates that she requires further teaching. All other options indicate that the mother understands the home care measures after surgical evacuation and repair of a paravaginal hematoma.

After surgical evacuation and repair of a paravaginal hematoma, a client is discharged 3 days postpartum. The nurse determines that the client needs further discharge instructions when the client makes which statement? 1."I will probably need my mother to help me with housekeeping." 2."Because I am so sore, I will nurse the baby while lying on my side." 3."My husband and I will not have intercourse until the stitches are healed." 4."The only medications I will take are prenatal vitamins and stool softeners."

A (A newborn who has not voided in 24 hours may have any of a number of problems, some of which deserve the attention of the pediatrician. Formula-fed infants tend to void more frequently in the first 3 days; breastfed infants void less during this time because the mother's breast milk has not come in yet. Brick dust may be uric acid crystals; blood spotting could be caused by withdrawal of maternal hormones (pseudomenstruation) or a circumcision. The physician must be notified only if there is no apparent cause of bleeding. Weight loss from fluid loss may take 14 days to regain.)

As related to the normal functioning of the renal system in newborns, nurses should be aware that: a. The pediatrician should be notified if the newborn has not voided in 24 hours. b. Breastfed infants likely will void more often during the first days after birth. c. "Brick dust" or blood on a diaper is always cause to notify the physician. d. Weight loss from fluid loss and other normal factors should be made up in 4 to 7 days.

B (The WBC count is high the first day of birth and then declines rapidly. Delayed clamping of the cord results in an increase in hemoglobin and the red blood cell count. The platelet count essentially is the same for newborns and adults. Clotting is sufficient to prevent hemorrhage unless the vitamin K deficiency is significant.)

By knowing about variations in infants' blood count, nurses can explain to their clients that: a. A somewhat lower than expected red blood cell count could be the result of delay in clamping the umbilical cord. b. The early high white blood cell (WBC) count is normal at birth and should decrease rapidly. c. Platelet counts are higher than in adults for a few months. d. Even a modest vitamin K deficiency means a problem with the ability of the blood to clot properly.

B (With the increase in the blood flow to the left atrium from the lungs, the pressure is increased, and the foramen ovale is functionally closed. The pressure in the right atrium decreases at birth. It is higher during fetal life. Blood flow increases to the left ventricle after birth. The hepatic blood flow changes, but that is not the reason for the closure of the foramen ovale.)

Cardiovascular changes that cause the foramen ovale to close at birth are a direct result of: a. Increased pressure in the right atrium. b. Increased pressure in the left atrium. c. Decreased blood flow to the left ventricle. d. Changes in the hepatic blood flow.

D (A psychologic factor is not one of the essential factors in the initiation of breathing; the fourth factor is sensory. The sensory factors include handling by the provider, drying by the nurse, lights, smells, and sounds. Chemical factors are essential for the initiation of breathing. During labor, decreased levels of oxygen and increased levels of carbon dioxide seem to have a cumulative effect that is involved in the initiation of breathing. Clamping of the cord may also contribute to the start of respirations. Prostaglandins are known to inhibit breathing, and clamping of the cord results in a drop in the level of prostaglandins. Mechanical factors also are necessary to initiate respirations. As the infant passes through the birth canal, the chest is compressed. With birth the chest is relaxed, which allows for negative intrathoracic pressure that encourages air to flow into the lungs. The profound change in temperature between intrauterine and extrauterine life stimulates receptors in the skin to communicate with the receptors in the medulla. This also contributes to the initiation of breathing.)

During life in utero, oxygenation of the fetus occurs through transplacental gas exchange. When birth occurs, four factors combine to stimulate the respiratory center in the medulla. The initiation of respiration then follows. Which is not one of these essential factors? a. Chemical b. Mechanical c. Thermal d. Psychologic

C (The bowel is initially sterile in the newborn, and vitamin K cannot be synthesized until food is introduced into the bowel. Vitamin K is necessary to activate blood clotting factors. The platelet count in term newborns is near adult levels. Vitamin K is necessary to activate prothrombin and other clotting factors.)

In administering vitamin K to the infant shortly after birth, the nurse understands that vitamin K is: a. Important in the production of red blood cells. b. Necessary in the production of platelets. c. Not initially synthesized because of a sterile bowel at birth. d. Responsible for the breakdown of bilirubin and prevention of jaundice.

B (Cephalhematomas are characterized by bleeding between the bone and its covering, the periosteum. Because of the breakdown of the red blood cells within a hematoma, the infants are at greater risk for jaundice. Cephalhematomas do not increase the risk for infections. Caput is an edematous area on the head from pressure against the cervix. Erythema toxicum is a benign rash of unknown cause that consists of blotchy red areas.)

Infants in whom cephalhematomas develop are at increased risk for: a. Infection. b. Jaundice. c. Caput succedaneum. d. Erythema toxicum.

A (Because the infant is wet with amniotic fluid and blood, heat loss by evaporation occurs quickly. Heat loss by convection occurs when drafts come from open doors and air currents created by people moving around. If the heat loss is caused by placing the baby near cold surfaces or equipment, it is referred to as a radiation heat loss. Conduction heat loss occurs when the baby comes in contact with cold objects or surfaces.)

Nurses can prevent evaporative heat loss in the newborn by: a. Drying the baby after birth and wrapping the baby in a dry blanket. b. Keeping the baby out of drafts and away from air conditioners. c. Placing the baby away from the outside wall and the windows. d. Warming the stethoscope and the nurse's hands before touching the baby.

3.Gently message the uterine fundus. The most frequent cause of excessive bleeding after childbirth is uterine atony. A major intervention to restore adequate tone is stimulation of the uterine muscle via gently massaging the uterine fundus. Options 1, 2, and 4 may be necessary but they are not initial actions. The initial action is to alleviate the problem. Additionally a health care provider's prescription is needed to administer a medication

On assessment of a client who is 30 minutes into the fourth stage of labor, the nurse finds the client's perineal pad saturated in blood and blood soaked into the bed linen under the client's buttocks. Which is the nurse's initial action? 1.Call the health care provider. 2.Assess the client's vital signs. 3.Gently message the uterine fundus. 4.Administer a 300-mL bolus of a 20 units/L oxytocin (Pitocin) solution.

1.Urinate frequently throughout the day. 2.Wipe the perineal area from front to back after urinating. 3.Fluid intake should be increased to at least 3000 mL/day. 4.Prescribed medication must be taken until it is completed. A client with a urinary tract infection should be instructed to drink at least 3000 mL of fluid each day to flush the infection from the bladder and urinate frequently throughout the day. The client is also taught to wipe the perineal area from front to back after urinating or having a bowel movement. A woman with a urinary tract infection must be encouraged to take the medication for the entire time it is prescribed. Foods and fluids that acidify the urine need to be encouraged.

On the second postpartum day, a client complains of burning, urgency, and frequency of urination. A urinalysis is obtained, and the results indicate the presence of a urinary tract infection. Which measures should the nurse instruct the client to take regarding the prevention and treatment of the infection? Select all that apply. 1.Urinate frequently throughout the day. 2.Wipe the perineal area from front to back after urinating. 3.Fluid intake should be increased to at least 3000 mL/day. 4.Prescribed medication must be taken until it is completed. 5.Foods and fluids that will increase urine alkalinity should be consumed.

D (The vulnerability of the brain likely is to the result of the cerebellum growth spurt. The neuromuscular system is almost completely developed at birth. The reflex system is not relevant. The various sleep-wake states are not relevant.)

One reason the brain is vulnerable to nutritional deficiencies and trauma in early infancy is the: a. Incompletely developed neuromuscular system. b. Primitive reflex system. c. Presence of various sleep-wake states. d. Cerebellum growth spurt.

A (In normal infant respiration the chest and abdomen rise synchronously, and breaths are shallow and irregular. Breathing with nasal flaring is a sign of respiratory distress. Diaphragmatic breathing with chest retraction is a sign of respiratory distress. Infant breaths are not deep with a regular rhythm.)

Part of the health assessment of a newborn is observing the infant's breathing pattern. A full-term newborn's breathing pattern is predominantly: a. Abdominal with synchronous chest movements. b. Chest breathing with nasal flaring. c. Diaphragmatic with chest retraction. d. Deep with a regular rhythm.

B (As the infant's skin begins to dry, the creases will appear more prominent, and the infant's gestation could be misinterpreted. Footprinting will not interfere with the creases. Heel sticks will not interfere with the creases. The creases will appear more prominent after 24 hours.)

Plantar creases should be evaluated within a few hours of birth because: a. The newborn has to be footprinted. b. As the skin dries, the creases will become more prominent. c. Heel sticks may be required. d. Creases will be less prominent after 24 hours.

A (This protection, vernix caseosa, is needed because the infant's skin is so thin. Surfactant is a protein that lines the alveoli of the infant's lungs. Caput succedaneum is the swelling of the tissue over the presenting part of the fetal head. Acrocyanosis is cyanosis of the hands and feet that results in a blue coloring.)

The cheeselike, whitish substance that fuses with the epidermis and serves as a protective coating is called: a. Vernix caseosa. b. Surfactant. c. Caput succedaneum. d. Acrocyanosis.

B (NOT: Other clusters of neonatal behavior include motor performance, quality of movement and tone and reflexes, and assessment of neonatal reflexes.)

The healthy infant must accomplish both behavioral and biologic tasks to develop normally. Behavioral characteristics form the basis of the social capabilities of the infant. Newborns pass through a hierarchy of developmental challenges as they adapt to their environment and caregivers. This progression in behavior is the basis for the Brazelton Neonatal Behavioral Assessment (NBAS). Please match the cluster of neonatal behavior with the correct level on the NBAS scale. Ability to attend to visual and auditory stimuli while alert. a. Habituation b. Orientation c. Range of state d. Autonomic stability e. Regulation of state

A (NOT: Other clusters of neonatal behavior include motor performance, quality of movement and tone and reflexes, and assessment of neonatal reflexes.)

The healthy infant must accomplish both behavioral and biologic tasks to develop normally. Behavioral characteristics form the basis of the social capabilities of the infant. Newborns pass through a hierarchy of developmental challenges as they adapt to their environment and caregivers. This progression in behavior is the basis for the Brazelton Neonatal Behavioral Assessment (NBAS). Please match the cluster of neonatal behavior with the correct level on the NBAS scale. Ability to respond to discrete stimuli while asleep a. Habituation b. Orientation c. Range of state d. Autonomic stability e. Regulation of state

E (NOT: Other clusters of neonatal behavior include motor performance, quality of movement and tone and reflexes, and assessment of neonatal reflexes.)

The healthy infant must accomplish both behavioral and biologic tasks to develop normally. Behavioral characteristics form the basis of the social capabilities of the infant. Newborns pass through a hierarchy of developmental challenges as they adapt to their environment and caregivers. This progression in behavior is the basis for the Brazelton Neonatal Behavioral Assessment (NBAS). Please match the cluster of neonatal behavior with the correct level on the NBAS scale. How the infant responds when aroused a. Habituation b. Orientation c. Range of state d. Autonomic stability e. Regulation of state

C (NOT: Other clusters of neonatal behavior include motor performance, quality of movement and tone and reflexes, and assessment of neonatal reflexes.)

The healthy infant must accomplish both behavioral and biologic tasks to develop normally. Behavioral characteristics form the basis of the social capabilities of the infant. Newborns pass through a hierarchy of developmental challenges as they adapt to their environment and caregivers. This progression in behavior is the basis for the Brazelton Neonatal Behavioral Assessment (NBAS). Please match the cluster of neonatal behavior with the correct level on the NBAS scale. Measure of general arousability. a. Habituation b. Orientation c. Range of state d. Autonomic stability e. Regulation of state

D (NOT: Other clusters of neonatal behavior include motor performance, quality of movement and tone and reflexes, and assessment of neonatal reflexes.)

The healthy infant must accomplish both behavioral and biologic tasks to develop normally. Behavioral characteristics form the basis of the social capabilities of the infant. Newborns pass through a hierarchy of developmental challenges as they adapt to their environment and caregivers. This progression in behavior is the basis for the Brazelton Neonatal Behavioral Assessment (NBAS). Please match the cluster of neonatal behavior with the correct level on the NBAS scale. Signs of stress related to homeostatic adjustment a. Habituation b. Orientation c. Range of state d. Autonomic stability e. Regulation of state

D (The most critical adjustment of a newborn at birth is the establishment of respirations. The cardiovascular system changes markedly after birth as a result of fetal respiration, which reduces pulmonary vascular resistance to the pulmonary blood flow and initiates a chain of cardiac changes that support the cardiovascular system. The infant relies on passive immunity received from the mother for the first 3 months of life. After the establishment of respirations, heat regulation is critical to newborn survival.)

The nurse assessing a newborn knows that the most critical physiologic change required of the newborn is: a. Closure of fetal shunts in the circulatory system. b. Full function of the immune defense system at birth. c. Maintenance of a stable temperature. d. Initiation and maintenance of respirations.

4.Retained placental fragments from delivery Retained placental fragments and infections are the primary causes of subinvolution. When either of these processes is present, the uterus has difficulty contracting. The presence of afterpains is an expected finding following delivery. Options 2 and 3 are not causes of subinvolution.

The nurse caring for a client with a diagnosis of subinvolution should understand that which is a primary cause of this diagnosis? 1.Afterpains 2.Increased estrogen levels 3.Increased progesterone levels 4.Retained placental fragments from delivery

A (The visual system continues to develop for the first 6 months. As soon as the amniotic fluid drains from the ear (minutes), the infant's hearing is similar to that of an adult. Newborns have a highly developed sense of smell. The newborn can distinguish and react to various tastes.)

The nurse caring for the newborn should be aware that the sensory system least mature at the time of birth is: a. Vision. b. Hearing. c. Smell. d. Taste.

A new father wants to know what medication was put into his infant's eyes and why it is needed. The nurse explains to the father that the purpose of the Ilotycin ophthalmic ointment is to: a. Destroy an infectious exudate caused by Staphylococcus that could make the infant blind. b. Prevent gonorrheal and chlamydial infection of the infant's eyes potentially acquired from the birth canal.

b. Prevent gonorrheal and chlamydial infection of the infant's eyes potentially acquired from the birth canal.

4.The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding. Hepatitis B virus is highly contagious and is transmitted by direct contact with blood and body fluids of infected persons. The rationale for identifying childbearing clients with this disease is to provide adequate protection of the fetus and the newborn, to minimize transmission to other individuals, and to reduce maternal complications. The correct option provides the best evaluation of maternal understanding of disease transmission. Option 1 will not affect disease transmission. Options 2 and 3 are appropriate feeding techniques for bottle-feeding, but do not minimize disease transmission for hepatitis B.

The nurse evaluates the ability of a hepatitis B-positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn? 1.The mother requests that the window be closed before feeding. 2.The mother holds the newborn properly during feeding and burping. 3.The mother tests the temperature of the formula before initiating feeding. 4.The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding.

1."I should apply my antiembolism stockings after breakfast." The nurse should instruct the client to apply antiembolism stockings before the client rises in the morning to prevent the venous congestion that will begin as soon as the mother gets up. Circulation can be improved with a regular schedule of activity, preferably walking, and the mother should be instructed to avoid prolonged standing or sitting in one position and avoid placing pillows under the knees because of the risk venous stasis in the lower extremities. The mother also should be encouraged to maintain a fluid intake of at least 2500 mL/day to prevent dehydration and consequent sluggish circulation.

The nurse has provided instructions for a postpartum client at risk for thrombosis regarding measures to prevent its occurrence. Which statement, if made by the client, indicates a need for further education? 1."I should apply my antiembolism stockings after breakfast." 2."I should avoid prolonged standing or sitting in one position." 3."I should perform regularly scheduled exercise such as walking." 4."I should avoid using pillows under my knees to prevent pressure in the back of my knee area."

4.The mother requests that the nurse feed the newborn because she is feeling fatigued. The nurse should be alert to maladaptive interaction in the maternal-infant bonding processes. If the nurse notes that the mother is avoiding interaction with the newborn or is avoiding caring for the newborn, the nurse should suspect the potential for a maladaptive interaction. Talking to the newborn or willingness to perform cord care does not indicate a maladaptive response. Expressing discomfort with the new role of motherhood is a normal, expected process, and it is important for the mother to verbalize concerns.

The nurse in the postpartum unit is observing the mother-infant bonding process in a client. Which observation, if made by the nurse, indicates the potential for a maladaptive interaction? 1.The mother is observed talking to the newborn. 2.The mother performs cord care for the newborn. 3.The mother verbalizes discomfort with the new role of motherhood. 4.The mother requests that the nurse feed the newborn because she is feeling fatigued.

1.Massage the uterus until firm. When uterine atony occurs, the initial nursing action would be to massage the uterus until it is firm. If this does not assist in controlling blood loss, then the nurse would contact the HCP. Additionally, once bleeding is under control, the nurse would monitor the vital signs and estimate the amount of blood loss

The nurse is assessing a client in the postpartum period and suspects the presence of uterine atony. Which is the initial nursing action? 1.Massage the uterus until firm. 2.Take the client's blood pressure. 3.Contact the health care provider (HCP). 4.Assess the amount of drainage on the peripad.

3.Instruct the client to request help when getting out of bed. Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that caution the nurse to focus interventions on the client's safety. The nurse should advise the client to get help the first few times she gets out of bed. Option 1 is not a helpful action in this situation and would not relieve the symptoms. Option 2 requires a health care provider's prescription. Option 4 is unnecessary.

The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action would be most appropriate? 1.Raise the head of the client's bed. 2.Obtain hemoglobin and hematocrit levels. 3.Instruct the client to request help when getting out of bed. 4.Inform the nursery room nurse to avoid bringing the newborn to the client until the mother's symptoms have subsided.

2.Elevation of the affected extremity Thrombosis that is limited to the superficial veins of the saphenous system is treated with analgesics, rest, and elastic support stockings. Elevation of the affected lower extremity to improve venous return also may be recommended. Warm packs may be prescribed to be applied to the affected area to promote healing. There is usually no need for anticoagulants or anti-inflammatory agents unless the condition persists. Bed rest or limited activity may be prescribed depending on health care provider preference.

The nurse is developing a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse anticipates that which intervention will be prescribed? 1.Administration of anticoagulants 2.Elevation of the affected extremity 3.Ambulation eight to ten times daily 4.Application of ice packs to the affected area

3.The saturation of more than one peripad per hour Saturation of more than one peripad per hour is considered excessive even in the early postpartum period. In the first 24 hours after birth, the uterus will feel like a firmly contracted ball, roughly the size of a large grapefruit. One easily can locate the uterus at the level of the umbilicus. Lochia should be dark red and moderate in amount.

The nurse is monitoring a postpartum client in the fourth stage of labor. Which finding, if noted by the nurse, would indicate a complication related to a laceration of the birth canal? 1.Presence of dark red lochia 2.Palpation of the uterus as a firm contracted ball 3.The saturation of more than one peripad per hour 4.Palpation of the fundus at the level of the umbilicus

A (An infant who is dusky and becomes cyanotic when crying is showing poor adaptation to extrauterine life. Acrocyanosis is an expected finding during the early neonatal life. This is within normal range for a newborn. Infants enter the period of deep sleep when they are about 1 hour old.)

The nurse should immediately alert the physician when: a. The infant is dusky and turns cyanotic when crying. b. Acrocyanosis is present at age 1 hour. c. The infant's blood glucose level is 45 mg/dL. d. The infant goes into a deep sleep at age 1 hour.

3.Heavy Lochia is the discharge from the uterus in the postpartum period; it consists of blood from the vessels of the placental site and debris from the decidua. The following can be used as a guide to determine the amount of flow: scant = less than 2.5 cm (<1 inch) on menstrual pad in 1 hour; light = less than 10 cm (<4 inches) on menstrual pad in 1 hour; moderate = less than 15 cm (<6 inches) on menstrual pad in 1 hour; heavy = saturated menstrual pad in 1 hour; and excessive = menstrual pad saturated in 15 minutes.

The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 1 hour. How should the nurse document this finding? 1.Scant 2.Light 3.Heavy 4.Excessive

1.Client pain level The priority nursing consideration for a client who delivered 2 hours ago and who has a midline episiotomy and hemorrhoids is client pain level. Most clients have some degree of discomfort during the immediate postpartum period. There are no data in the question that indicate inadequate urinary output, the presence of client perception of body changes, and potential for imbalanced body fluid volume.

The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client had a midline episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client? 1.Client pain level 2.Inadequate urinary output 3.Client perception of body changes 4.Potential for imbalanced body fluid volume

1.Wear a supportive bra. 2.Rest during the acute phase. 3.Maintain a fluid intake of at least 3000 mL. 4.Continue to breast-feed if the breasts are not too sore. Mastitis is an infection of the lactating breast. Client instructions include resting during the acute phase, maintaining a fluid intake of at least 3000 mL/day (if not contraindicated), and taking analgesics to relieve discomfort. Antibiotics may be prescribed and are taken until the complete prescribed course is finished. They are not stopped when the soreness subsides. Additional supportive measures include the use of moist heat or ice packs and wearing a supportive bra. Continued decompression of the breast by breast-feeding or breast pump is important to empty the breast and prevent the formation of an abscess.

The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. 1.Wear a supportive bra. 2.Rest during the acute phase. 3.Maintain a fluid intake of at least 3000 mL. 4.Continue to breast-feed if the breasts are not too sore. 5.Take the prescribed antibiotics until the soreness subsides. 6.Avoid decompression of the breasts by breast-feeding or breast pump.

3.500 If the client is breast-feeding, her calorie needs increase by approximately 500 cal/day. The client should also be instructed regarding the need for increased fluids and the need for prenatal vitamins and iron supplements.

The nurse is providing nutritional counseling to a new mother who is breast-feeding her newborn. The nurse should instruct the client that her calorie needs should increase by approximately how many calories a day? 1.100 2.300 3.500 4.1000

1."I should wear a bra that provides support." 2."Drinking alcohol can affect my milk supply." 3."The use of caffeine can decrease my milk supply." 6."I plan on having bottled water available in the refrigerator so I can get additional fluids easily." The postpartum client should wear a bra that is well-fitted and supportive. Breasts may leak between feedings or during coitus, and the client is taught to place a breast pad in the bra. Breast-feeding clients should increase their daily fluid intake; having bottled water available indicates that the postpartum client understands the importance of increasing fluids. If engorgement occurs, the client should not limit breast-feeding, but should breast-feed frequently. Oral contraceptives containing estrogen are not recommended for breast-feeding mothers. Common causes of decreased milk supply include formula use; inadequate rest or diet; smoking by the mother or others in the home; and use of caffeine, alcohol, or other medications.

The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all that apply. 1."I should wear a bra that provides support." 2."Drinking alcohol can affect my milk supply." 3."The use of caffeine can decrease my milk supply." 4."I will start my estrogen birth control pills again as soon as I get home." 5."I know if my breasts get engorged I will limit my breast-feeding and supplement the baby." 6."I plan on having bottled water available in the refrigerator so I can get additional fluids easily."

4.Leaving the infant with the client so that she will be required to provide the care A client with no experience of handling infants may be fearful and reluctant to handle her newborn or to take on physical care on her own. Leaving the infant with the mother so that she will be required to provide the care will produce additional apprehension. Acceptance of her feelings and acknowledgment of the apprehension can help an unsure mother begin to participate in caring for her newborn. Assistance will help the client become more at ease.

The nurse is teaching a new mother how to care for her newborn. The nurse notes that the client is very fearful and reluctant to handle the newborn and notes that this is the client's first child. Which nursing intervention is least appropriate in assisting the promotion of mother-infant interaction and bonding? 1.Accepting the client's feelings 2.Acknowledging the client's apprehension 3.Assisting the client with giving the baths to allow her to become more at ease 4.Leaving the infant with the client so that she will be required to provide the care

4.Assess for hypovolemia and notify the health care provider (HCP). -Symptoms of hypovolemia include cool, clammy, pale skin, sensations of anxiety or impending doom, restlessness, and thirst. When these symptoms are present, the nurse should further assess for hypovolemia and notify the HCP. Providing oral fluids and beginning fundal massage and beginning hourly pad counts and reassuring the client will delay necessary treatment. Also, the question gives no indication of the cause of the hypovolemia or that the client is hemorrhaging and that fundal massage is needed. The head of the bed is not elevated in a hypovolemic condition.

The nurse performs an assessment on a client who is 4 hours postpartum. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. What immediate action should the nurse take? 1.Provide oral fluids and begin fundal massage. 2.Begin hourly pad counts and reassure the client. 3.Elevate the head of the bed and assess vital signs. 4.Assess for hypovolemia and notify the health care provider (HCP).

2.A 26-year-old woman with a family history of thrombophlebitis Certain factors create a risk for the development of thromboembolic disorders. These include smoking, varicose veins, obesity, a history of thrombophlebitis, women older than 35 years or who have had more than three pregnancies, and women who have had a cesarean birth. From the options presented, a 26-year-old woman with a family history of thrombophlebitis is least likely to develop thromboembolic disorders in the postpartum period.

The nurse who is employed in a prenatal clinic is performing prenatal assessments on clients who are in their first trimester of pregnancy. The nurse is concerned with identifying clients who may be at risk for the development of postpartum complications. Which client would be at the lowest risk for development of postpartum thromboembolic disorders? 1.A 39-year-old woman who reports that she smokes 2.A 26-year-old woman with a family history of thrombophlebitis 3.A 37-year-old woman in her fourth pregnancy who is overweight 4.A 22-year-old woman with a first pregnancy who states that oral contraceptives taken in the past have caused thrombophlebitis

4."The client is self-focused and talks to others about labor." Rubin has identified three phases of regeneration during the postpartum period. The taking-in phase occurs in the first 3 days postpartum, and the taking-hold phase occurs between days 3 to 10. During the taking-in phase, the new mother is attempting to integrate her labor and birth experience. She tends to need sleep and feels fatigued, talks about labor, and is self-focused and dependent. In the taking-hold phase, the client is more active, independent, initiates activities, and partakes in mothering tasks. In the letting-go phase, the mother may grieve over the separation of the baby from part of her body.

The nursing instructor is reviewing the plan of care with a student regarding care of a postpartum client. The instructor asks the nursing student about the taking-in phase according to Rubin's phases of regeneration and the client behaviors that are most likely to occur during this phase. Which response made by the student indicates an understanding of this phase? 1."The client would be independent." 2."The client initiates activities on her own." 3."The client participates in mothering tasks." 4."The client is self-focused and talks to others about labor."

B ("Infants can track their parent's eyes and distinguish patterns; they prefer complex patterns" is an accurate statement. Development of the visual system continues for the first 6 months of life. Visual acuity is difficult to determine, but the clearest visual distance for the newborn appears to be 19 cm. Infants prefer to look at complex patterns, regardless of the color. Infants prefer low illumination and withdraw from bright light.)

The parents of a newborn ask the nurse how much the newborn can see. The parents specifically want to know what type of visual stimuli they should provide for their newborn. The nurse responds to the parents by telling them: a. "Infants can see very little until about 3 months of age." b. "Infants can track their parent's eyes and distinguish patterns; they prefer complex patterns." c. "The infant's eyes must be protected. Infants enjoy looking at brightly colored stripes." d. "It's important to shield the newborn's eyes. Overhead lights help them see better."

2.Retained placental fragments from delivery Retained placental fragments and infection are the primary causes of subinvolution. When either of these processes is present, the uterus will have difficulty contracting. An oral temperature of 99.0° F after delivery and the presence of afterpains are expected findings following delivery. Option 4 is not a cause of subinvolution and is unrelated to the subject of the question.

The postpartum nurse is caring for a woman who just delivered a healthy newborn. The nurse should be most concerned with the presence of subinvolution if which occurs? 1.The presence of afterpains 2.Retained placental fragments from delivery 3.An oral temperature of 99.0° F following delivery 4.Increased estrogen and progesterone levels as noted on laboratory analysis

1.3 days postpartum After birth, the nurse should auscultate the client's abdomen in all four quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days postpartum. Surgery, anesthesia, and the use of opioids and pain control agents also contribute to the longer period of altered bowel functions. Options 2, 3, and 4 are incorrect.

The postpartum nurse is providing instructions to a client after delivery of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function? 1.3 days postpartum 2.7 days postpartum 3.On the day of delivery 4.Within 2 weeks postpartum

4.Increase hydration by encouraging oral fluids. The client's temperature should be taken every 4 hours while she is awake. Temperatures up to 100.4° F (38° C) in the first 24 hours after birth often are related to the dehydrating effects of labor. The appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. Although the nurse also would document the findings, the appropriate action would be to increase hydration. Taking the temperature in another 15 minutes is an unnecessary action. Contacting the HCP is not necessary.

The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2° F. What is the priority nursing action? 1.Document the findings. 2.Retake the temperature in 15 minutes. 3.Notify the health care provider (HCP). 4.Increase hydration by encouraging oral fluids.

4."If I notice any pain, redness, or swelling in my breasts, I should contact the health care provider." Signs of infection include pain, redness, heat, and swelling of a localized area of the breast. If these symptoms occur, the client needs to contact the HCP. Options 1, 2, and 3 are normal changes that occur in the postpartum period.

The postpartum unit nurse has provided discharge instructions to a client planning to breast-feed her normal, healthy infant. Which statement by the client indicates an understanding of the instructions? "If I experience any sweating during the night, I should call the health care provider." 2."If I have uterine cramping while breast-feeding, I should contact the health care provider." 3."If I'm still having bloody vaginal drainage in a week, I should contact the health care provider." 4."If I notice any pain, redness, or swelling in my breasts, I should contact the health care provider."

B (Conjugation of bilirubin is the process of changing the bilirubin from a fat-soluble to a water-soluble product. This is the route by which part of the bile produced by the liver enters the intestine, is reabsorbed by the liver, and then is recycled into the intestine. Unconjugated bilirubin is fat soluble. Albumin binding is to attach something to a protein molecule.)

The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is known as: a. Enterohepatic circuit. b. Conjugation of bilirubin. c. Unconjugation of bilirubin. d. Albumin binding.

2."You should not become pregnant for 2 to 3 months after administration of the vaccine." -Rubella vaccine is a live attenuated virus that provides immunity for approximately 15 years. Because rubella is a live vaccine, it will act as a virus and is potentially harmful to the organogenesis phase of fetal development. Informed consent for rubella and varicella vaccination in the postpartum period includes information about possible side effects and the risk of teratogenic effects. The client should be informed about the potential effects of this vaccine and the need to avoid becoming pregnant for 2 to 3 months (or as indicated by the health care provider) after administration of the vaccine. Abstinence from sexual intercourse is unnecessary. Heat or extreme changes in temperature have no effect on the person who has been vaccinated. The vaccine is not known to cause anaphylactic reactions.

The rubella vaccine has been prescribed for a new mother. Which statement should the postpartum nurse make when providing information about the vaccine to the client? 1."You should avoid sexual intercourse for 2 weeks after administration of the vaccine." 2."You should not become pregnant for 2 to 3 months after administration of the vaccine." 3."You should avoid heat and extreme temperature changes for 1 week after administration of the vaccine." 4."You must sign an informed consent because anaphylactic reactions can occur with the administration of this vaccine."

B (Changes begin right after birth; the cutoff time when the transition is considered over (although the baby keeps changing) is 28 days. The transition period has three phases: first reactivity, decreased response, and second reactivity. All newborns experience this transition regardless of age or type of birth. Although stress can cause variation in the phases, the mother's age and wealth do not disturb the pattern.)

The transition period between intrauterine and extrauterine existence for the newborn: a. Consists of four phases, two reactive and two of decreased responses. b. Lasts from birth to day 28 of life. c. Applies to full-term births only. d. Varies by socioeconomic status and the mother's age.

B, C, D (Convection, radiation, evaporation, and conduction are the four modes of heat loss in the newborn. Perspiration and urination are not modes of heat loss in newborns.)

What are modes of heat loss in the newborn (Select all that apply)? a. Perspiration b. Convection c. Radiation d. Conduction e. Urination

D (The newborn's flexed position guards against heat loss because it reduces the amount of body surface exposed to the environment. The newborn's body is able to constrict the peripheral blood vessels to reduce heat loss. Burning brown fat generates heat. The respiratory rate may rise to stimulate muscular activity, which generates heat.)

What infant response to cool environmental conditions is either not effective or not available to them? a. Constriction of peripheral blood vessels b. Metabolism of brown fat c. Increased respiratory rates d. Unflexing from the normal position

C (Petechiae (bruises) scattered over the infant's body should be reported to the pediatrician because they may indicate underlying problems. Mongolian spots are bluish-black spots that resemble bruises but fade gradually over months and have no clinical significance. Telangiectatic nevi (stork bites, angel kisses) fade by the second year and have no clinical significance. Erythema toxicum is an appalling-looking rash, but it has no clinical significance and requires no treatment.)

What marks on a baby's skin may indicate an underlying problem that requires notification of a physician? a. Mongolian spots on the back b. Telangiectatic nevi on the nose or nape of the neck c. Petechiae scattered over the infant's body d. Erythema toxicum anywhere on the body

3.Notify the health care provider. Normally, a few small clots may be noted in the lochia in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the appropriate action is to notify the HCP. Reassessing the client in 2 hours would delay necessary treatment. Increasing oral intake of fluids would not be a helpful action in this situation.

When performing a postpartum assessment on a client, a nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate? 1.Document the findings. 2.Reassess the client in 2 hours. 3.Notify the health care provider. 4.Encourage increased oral intake of fluids.

2.Massage distended areas as the infant nurses. Massaging the distended areas as the infant nurses will encourage complete emptying of the breast and prevent milk stasis. Each breast should be offered at each feeding to prevent milk stasis and ensure adequate milk supply. Soap should not be used on the nipples because of the risk of drying or cracking. If early signs of mastitis occur, the client usually will be instructed to nurse the infant more frequently, because infant sucking is thought to empty the breast more completely.

When planning care for a postpartum client that plans to breast-feed her infant, which important piece of information should the nurse include in the teaching plan to prevent the development of mastitis? 1.Offer only one breast at each feeding. 2.Massage distended areas as the infant nurses. 3.Cleanse nipples with a mild antibacterial soap before and after infant feedings. 4.Express and discard milk from the affected breast at the first signs of mastitis.

A (The Babinski reflex causes the toes to flare outward and the big toe to dorsiflex. The tonic neck reflex (also called the fencing reflex) refers to the posture assumed by newborns when in a supine position. The stepping reflex occurs when infants are held upright with their heel touching a solid surface and the infant appears to be walking. Plantar grasp reflex is similar to the palmar grasp reflex: when the area below the toes is touched, the infant's toes curl over the nurse's finger.)

Which newborn reflex is elicited by stroking the lateral sole of the infant's foot from the heel to the ball of the foot? a. Babinski b. Tonic neck c. Stepping d. Plantar grasp

D (Breastfeeding is associated with an increased incidence of jaundice. Neonatal jaundice occurs in 60% of newborns; the complication called kernicterus is rare. Jaundice in the first 24 hours or that persists past day 7 is cause for medical concern. Parents need to know how to assess for jaundice in their newborn.)

Which statement describing physiologic jaundice is incorrect? a. Neonatal jaundice is common, but kernicterus is rare. b. The appearance of jaundice during the first 24 hours or beyond day 7 indicates a pathologic process. c. Because jaundice may not appear before discharge, parents need instruction on how to assess it and when to call for medical help. d. Breastfed babies have a lower incidence of jaundice.

D (The first phase is an active phase in which the baby is alert. Decreased activity and sleep mark the second phase. The first phase is the shortest, lasting less than 30 minutes. Such exploratory behaviors include spontaneous startle reactions. In the first phase the newborn also produces saliva.)

Which statement describing the first phase of the transition period is inaccurate? a. It lasts no longer than 30 minutes. b. It is marked by spontaneous tremors, crying, and head movements. c. It includes the passage of meconium. d. It may involve the infant's suddenly sleeping briefly.

C (Erythema toxicum (or erythema neonatorum) is a newborn rash that resembles flea bites. This is a normal finding that does not require notification of the physician, isolation of the newborn, or any additional interventions.)

While assessing the integument of a 24-hour-old newborn, the nurse notes a pink, papular rash with vesicles superimposed on the thorax, back, and abdomen. The nurse should: a. Notify the physician immediately. b. Move the newborn to an isolation nursery. c. Document the finding as erythema toxicum. d. Take the newborn's temperature and obtain a culture of one of the vesicles.

C (The average infant heart rate while awake is 120 to 160 beats/min. The newborn's heart rate may be about 85 to 100 beats/min while sleeping. The infant's heart rate typically is a bit higher when alert but quiet. A heart rate of 150 to 180 beats/min is typical when the infant cries.)

While assessing the newborn, the nurse should be aware that the average expected apical pulse range of a full-term, quiet, alert newborn is: a. 80 to 100 beats/min. b. 100 to 120 beats/min. c. 120 to 160 beats/min. d. 150 to 180 beats/min.

D (The characteristics displayed by the infant are associated with a positive Moro reflex. The tonic neck reflex occurs when the infant extends the leg on the side to which the infant's head simultaneously turns. The glabellar reflex is elicited by tapping on the infant's head while the eyes are open. A characteristic response is blinking for the first few taps. The Babinski reflex occurs when the sole of the foot is stroked upward along the lateral aspect of the sole and then across the ball of the foot. A positive response occurs when all the toes hyperextend, with dorsiflexion of the big toe.)

While evaluating the reflexes of a newborn, the nurse notes that with a loud noise the newborn symmetrically abducts and extends his arms, his fingers fan out and form a "C" with the thumb and forefinger, and he has a slight tremor. The nurse would document this finding as a positive: a. Tonic neck reflex. b. Glabellar (Myerson) reflex. c.Babinski reflex. d. Moro reflex.

C (The Ortolani maneuver is used to detect the presence of hip dysplasia. Polydactyly is the presence of extra digits. Clubfoot (talipes equinovarus) is a deformity in which the foot turns inward and is fixed in a plantar-flexion position. Webbing, or syndactyly, is a fusing of the fingers or toes.)

While examining a newborn, the nurse notes uneven skin folds on the buttocks and a click when performing the Ortolani maneuver. The nurse recognizes these findings as a sign that the newborn probably has: a. Polydactyly. b. Clubfoot. c. Hip dysplasia. d. Webbing

To prevent the abduction of newborns from the hospital, the nurse should: a. Instruct the mother not to give her infant to anyone except the one nurse assigned to her that day. b. Apply an electronic and identification bracelet to mother and infant. c. Carry the infant when transporting him or her in the halls. d. Restrict the amount of time infants are out of the nursery.

b. Apply an electronic and identification bracelet to mother and infant.

C (Avoiding overfeeding can also reduce regurgitation. The newborn's cheeks are full because of well-developed sucking pads. Teeth do develop in utero, but the nipple is placed deep because the baby cannot move food from the lips to the pharynx. Bacteria are not present at birth, but they soon enter through various orifices.)

With regard to the gastrointestinal (GI) system of the newborn, nurses should be aware that: a. The newborn's cheeks are full because of normal fluid retention. b. The nipple of the bottle or breast must be placed well inside the baby's mouth because teeth have been developing in utero, and one or more may even be through. c. Regurgitation during the first day or two can be reduced by burping the infant and slightly elevating the baby's head. d. Bacteria are already present in the infant's GI tract at birth because they traveled through the placenta.

C (The newborn's thin chest wall often allows the PMI to be seen. The normal heart rate for infants who are not sleeping is 120 to 160 beats/min. However, a crying infant temporarily could have a heart rate of 180 beats/min. Heart murmurs during the first few days of life have no pathologic significance; an irregular heart rate past the first few hours should be evaluated further. Persistent tachycardia may indicate RDS; bradycardia may be a sign of congenital heart blockage.)

With regard to the newborn's developing cardiovascular system, nurses should be aware that: a. The heart rate of a crying infant may rise to 120 beats/min. b. Heart murmurs heard after the first few hours are cause for concern. c. The point of maximal impulse (PMI) often is visible on the chest wall. d. Persistent bradycardia may indicate respiratory distress syndrome (RDS).

A (The first breath produces a cry. Newborns continue to expel fluid for the first hour of life. Newborns are natural nose breathers; they may not have the mouth-breathing response to nasal blockage for 3 weeks. Seesaw respirations instead of normal abdominal respirations are not normal and should be reported.)

With regard to the respiratory development of the newborn, nurses should be aware that: a. The first gasping breath is an exaggerated respiratory reaction within 1 minute of birth. b. Newborns must expel the fluid from the respiratory system within a few minutes of birth. c. Newborns are instinctive mouth breathers. d. Seesaw respirations are no cause for concern in the first hour after birth.

Baby-friendly hospitals mandate their infants be put to breast within the first _______ after birth. a) 1 hour b) 30 minutes c) 2 hours d) 4 hours

a) 1 hour

A 3.8-kg infant was delivered vaginally at 39 weeks after a 30-minute second stage. There was a nuchal cord. After birth the infant is noted to have petechiae over the face and upper back. Information given to the infant's parents should be based on the knowledge that petechiae: a. Are benign if they disappear within 48 hours of birth. b. Result from increased blood volume. c. Should always be further investigated. d. Usually occur with forceps delivery.

a. Are benign if they disappear within 48 hours of birth.

The nurse is using the Ballard scale to determine the gestational age of a newborn. Which assessment finding is consistent with a gestational age of 40 weeks? a. Flexed posture b. Abundant lanugo

a. Flexed posture

Nursing follow-up care often includes home visits for the new mother and her infant. Which information related to home visits is correct? a. Ideally, the visit is scheduled within 72 hours after discharge. b. Home visits are available in all areas. c. Visits are completed within a 30-minute time frame. d. Blood draws are not a part of the home visit.

a. Ideally, the visit is scheduled within 72 hours after discharge.

When preparing to administer a hepatitis B vaccine to a newborn, the nurse should: a. Obtain a syringe with a 25-gauge, 5/8-inch needle. b. Confirm that the newborn's mother has been infected with the hepatitis B virus. c. Assess the dorsogluteal muscle as the preferred site for injection. d. Confirm that the newborn is at least 24 hours old.

a. Obtain a syringe with a 25-gauge, 5/8-inch needle.

Hearing loss is one of the genetic disorders included in the universal screening program. Auditory screening of all newborns within the first month of life is recommended by the American Academy of Pediatrics. Reasons for having this testing performed include (Select all that apply): a. Prevention or reduction of developmental delay. b. Reassurance for concerned new parents. c. Early identification and treatment. d. Helping the child communicate better. e. Recommendation by the Joint Committee on Infant Hearing.

a. Prevention or reduction of developmental delay. c. Early identification and treatment. d. Helping the child communicate better. e. Recommendation by the Joint Committee on Infant Hearing.

Pain should be assessed regularly in all newborn infants. If the infant is displaying physiologic or behavioral cues indicating pain, measures should be taken to manage the pain. Examples of nonpharmacologic pain management techniques include (Select all that apply): a. Swaddling. b. Nonnutritive sucking. c. Skin-to-skin contact with the mother. d. Sucrose. e. Acetaminophen.

a. Swaddling. b. Nonnutritive sucking. c. Skin-to-skin contact with the mother. d. Sucrose.

Nurses can assist parents who are trying to decide whether their son should be circumcised by explaining: a. The pros and cons of the procedure during the prenatal period. b. That the American Academy of Pediatrics (AAP) recommends that all newborn boys be routinely circumcised. c. That circumcision is rarely painful and any discomfort can be managed without medication. d. That the infant will likely be alert and hungry shortly after the procedure.

a. The pros and cons of the procedure during the prenatal period.

With regard to umbilical cord care, nurses should be aware that: a. The stump can easily become infected. b. A nurse noting bleeding from the vessels of the cord should immediately call for assistance. c. The cord clamp is removed at cord separation. d. The average cord separation time is 5 to 7 days.

a. The stump can easily become infected.

The nurse examines a woman 1 hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action is to: a) Place her on a bedpan to empty her bladder b) Massage her fundus c) Call the physician d) Administer methylergonovine (Methergine), 0.2mg IM, which has been ordered prn

b) Massage her fundus

The nurse's initial action when caring for an infant with a slightly decreased temperature is to: a. Notify the physician immediately. b. Place a cap on the infant's head and have the mother perform kangaroo care.

b. Place a cap on the infant's head and have the mother perform kangaroo care.

During the complete physical examination 24 hours after birth: a. The parents are excused to reduce their normal anxiety. b. The nurse can gauge the neonate's maturity level by assessing the infant's general appearance. c. Once often neglected, blood pressure is now routinely checked. d. When the nurse listens to the heart, the S1 and S2 sounds can be heard; the first sound is somewhat higher in pitch and sharper than the second.

b. The nurse can gauge the neonate's maturity level by assessing the infant's general appearance.

Excessive blood loss after childbirth can have several causes; however, the most common is: a) Vaginal or vulvar hematomas b) Unrepaired lacerations of the vagina or cervix c) Failure of the uterine muscle to contract firmly d) Retained placental fragments

c) Failure of the uterine muscle to contract firmly

An infant boy was born just a few minutes ago. The nurse is conducting the initial assessment. Part of the assessment includes the Apgar score. The Apgar assessment is performed: a. Only if the newborn is in obvious distress. b. Once by the obstetrician, just after the birth. c. At least twice, 1 minute and 5 minutes after birth. d. Every 15 minutes during the newborn's first hour after birth.

c. At least twice, 1 minute and 5 minutes after birth.

The nurse administers vitamin K to the newborn for which reason? a. Most mothers have a diet deficient in vitamin K, which results in the infant's being deficient. b. Vitamin K prevents the synthesis of prothrombin in the liver and must be given by injection. c. Bacteria that synthesize vitamin K are not present in the newborn's intestinal tract. d. The supply of vitamin K is inadequate for at least 3 to 4 months, and the newborn must be supplemented.

c. Bacteria that synthesize vitamin K are not present in the newborn's intestinal tract.

A mother expresses fear about changing her infant's diaper after he is circumcised. What does the woman need to be taught to take care of the infant when she gets home? c. Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change. d. Wash off the yellow exudate that forms on the glans at least once every day to prevent infection.

c. Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change.

In the classification of newborns by gestational age and birth weight, the appropriate for gestational age (AGA) weight would: a. Fall between the 25th and 75th percentiles for the infant's age. b. Depend on the infant's length and the size of the head. c. Fall between the 10th and 90th percentiles for the infant's age. d. Be modified to consider intrauterine growth restriction (IUGR).

c. Fall between the 10th and 90th percentiles for the infant's age.

As related to laboratory tests and diagnostic tests in the hospital after birth, nurses should be aware that: a. All states test for phenylketonuria (PKU), hypothyroidism, cystic fibrosis, and sickle cell diseases. b. Federal law prohibits newborn genetic testing without parental consent. c. If genetic screening is done before the infant is 24 hours old, it should be repeated at age 1 to 2 weeks. d. Hearing screening is now mandated by federal law.

c. If genetic screening is done before the infant is 24 hours old, it should be repeated at age 1 to 2 weeks.

The nurse is performing a gestational age and physical assessment on the newborn. The infant appears to have an excessive amount of saliva. The nurse recognizes that this finding: a. Is normal. b. Indicates that the infant is hungry. c. May indicate that the infant has a tracheoesophageal fistula or esophageal atresia. d. May indicate that the infant has a diaphragmatic hernia.

c. May indicate that the infant has a tracheoesophageal fistula or esophageal atresia.

A newborn is jaundiced and receiving phototherapy via ultraviolet bank lights. An appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy by this method would be to: a. Apply an oil-based lotion to the newborn's skin to prevent dying and cracking. b. Limit the newborn's intake of milk to prevent nausea, vomiting, and diarrhea. c. Place eye shields over the newborn's closed eyes. d. Change the newborn's position every 4 hours.

c. Place eye shields over the newborn's closed eyes.

The normal term infant has little difficulty clearing the airway after birth. Most secretions are brought up to the oropharynx by the cough reflex. However, if the infant has excess secretions, the mouth and nasal passages can be cleared easily with a bulb syringe. When instructing parents on the correct use of this piece of equipment, it is important that the nurse teach them to: a. Avoid suctioning the nares. b. Insert the compressed bulb into the center of the mouth. c. Suction the mouth first. d. Remove the bulb syringe from the crib when finished.

c. Suction the mouth first.

As part of Standard Precautions, nurses wear gloves when handling the newborn. The chief reason is: a. To protect the baby from infection. c. To protect the nurse from contamination by the newborn.

c. To protect the nurse from contamination by the newborn.

Two hours after giving birth a primiparous woman becomes anxious and complains of intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm, at the umbilicus, and midline. Her lochia is moderate rubra with no clots. The nurse suspects: a) Bladder distention b) Uterine atony c) Constipation d) Hematoma formation

d) Hematoma formation

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse's first action is to: a) Begin an IV infusion of Ringer's lactate solution b) Assess the woman's vital signs c) Call the woman's primary health care provider d) Message the woman's fundus

d) Message the woman's fundus

Which finding would be a source of concern if noted during the assessment of a woman who is 12 hours' postpartum? a) Postural hypotension b) Temperature of 38 C c) Bradycardia- pulse rate of 55 beats/min d) Pain in left calf with dorsiflexion of left foot

d) Pain in left calf with dorsiflexion of left foot

Perineal care is an important infection control measure. When evaluation a postpartum woman's perineal care technique, the nurse would recognize the need for further instruction if the woman: a) Uses soap and warm water to wash the vulva and perineum b) Washes from symphysis pubis back to the episiotomy c) Changes her perineal pad every 2 to 3 hours d) Uses the peribottle to rinse upward into her vagina

d) Uses the peribottle to rinse upward into her vagina

An Apgar score of 10 at 1 minute after birth would indicate a(n): a. Infant having no difficulty adjusting to extrauterine life and needing no further testing. b. Infant in severe distress who needs resuscitation. c. Prediction of a future free of neurologic problems. d. Infant having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after birth.

d. Infant having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after birth.

As part of their teaching function at discharge, nurses should educate parents regarding safe sleep. Which statement is incorrect? a. Prevent exposure to people with upper respiratory tract infections. b. Keep the infant away from secondhand smoke. c. Avoid loose bedding, water beds, and beanbag chairs. d. Place the infant on his or her abdomen to sleep.

d. Place the infant on his or her abdomen to sleep.

When teaching parents about mandatory newborn screening, it is important for the nurse to explain that the main purpose is to: a. Keep the state records updated. b. Allow accurate statistical information. c. Document the number of births. d. Recognize and treat newborn disorders early.

d. Recognize and treat newborn disorders early.

Early this morning, an infant boy was circumcised using the PlastiBell method. The nurse tells the mother that she and the infant can be discharged after: a. The bleeding stops completely. b. Yellow exudate forms over the glans. c. The PlastiBell rim falls off. d. The infant voids.

d. The infant voids.

2.Ask the client to urinate and empty her bladder. Before fundal assessment is started, the nurse should ask the mother to empty her bladder so that an accurate assessment can be done. The nurse can then assess the bladder for complete emptying and accurately assess uterine involution. When performing fundal assessment, the woman is asked to lie flat on her back, with the knees flexed. Massaging the fundus is not appropriate unless the fundus is boggy or soft, and then it should be massaged gently until firm.

he nurse is preparing to perform a fundal assessment on a postpartum client. The nurse understands that which is the initial nursing action when performing this assessment? 1.Ask the client to turn on her side. 2.Ask the client to urinate and empty her bladder. 3.Massage the fundus gently before determining the level of the fundus. 4.Ask the client to lie flat on her back, with her knees and legs flat and straight.