postpartum/newborn nclex

A nurse is assisting in checking the reflexes on a neonate. In eliciting the Moro reflex, the nurse should perform which?

Clap the hand or slap on the mattress.

The nurse is caring for a postpartum client. At 4 hours postpartum, the client's temperature is 102° F (38.9° C). The appropriate nursing action would be to:

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

The parents of a male neonate who is not circumcised request information on how to clean the newborn's penis. Which of the following is the correct response for the nurse to make to the parents?

"Avoid retracting the foreskin to cleanse the glans because this may cause adhesions."

A pregnant client tests positive for the hepatitis B virus (HBV), and the client asks the nurse whether she will be able to breast-feed the baby as planned after delivery. The nurse makes which response to the client?

"Breast-feeding is allowed once the baby has been vaccinated."

A nurse is reviewing the treatment plan with the parents of a newborn infant with hypospadias. Which statement by the parents indicates their understanding of the plan?

"Circumcision has been delayed to save tissue for surgical repair."

On the second postpartum day, a woman complains of burning on urination, urgency, and frequency of urination. A urine sample is collected for urinalysis, and the results indicate the presence of a urinary tract infection. The nurse instructs the new mother regarding measures to take for the treatment of the infection. Which statement by the mother indicates the need for further instructions?

"Foods and fluids that will increase urine alkalinity should be consumed."

A nurse is instructing a postpartum client with endometritis about preventing the spread of infection to the newborn. Which of the following statements would the nurse make to the client?

"Hands should be washed thoroughly before holding the infant."

A nurse is reinforcing instructions to a postpartum cesarean delivery client who is preparing for discharge. Which statement by the client indicates a need for more information?

"I can start doing abdominal exercises as soon as I get home."

A postpartum client is getting ready for discharge. The nurse suspects that the client is in need of further teaching related to breast-feeding when she states:

"I don't need birth control since I will be breast-feeding."

A nurse has provided instructions to the mother of a newborn that is not circumcised about measures to clean the penis. Which statement by the mother indicates an understanding of this procedure?

"I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions."

A postpartum nurse is providing instructions to a mother regarding how to provide a bath to the newborn. Which statement by the mother indicates the need for further instructions?

"I need to bathe my newborn after a feeding."

A nurse is caring for a client who delivered a healthy newborn 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 mother regarding care related to the infection. Which statement by the mother indicates the need for further instructions?

"I need to isolate my infant for 48 hours after starting the antibiotics."

A nurse is caring for a client who delivered a healthy newborn 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 mother regarding care related to the infection. Which statement by the mother indicates a need for further instruction?

"I need to isolate my infant for 48 hours after the starting the antibiotics."

A nurse is providing instructions to a mother who is bottle-feeding a baby and who is complaining of breast engorgement. Which statement by the client indicates a need for further instructions?

"I should avoid wearing a bra at this time."

A nurse is providing instructions to a client who had an episiotomy during the birthing process. Which statement by the client would indicate a need for further instructions?

"I should take sitz baths three or four times a day and test the water temperature to be sure that it is at 115° F."

A nurse reinforces discharge instructions to the mother of a 5-day-old postterm newborn who required ventilatory support for 3 days for meconium aspiration. Which of the following statements indicates that the mother needs further teaching?

"I understand that my baby will be susceptible to contracting all respiratory infections throughout his childhood."

A nurse attempts to encourage a new mother to understand and to accept the cesarean section that was necessary to deliver her baby, rather than to focus on the surgical aspect of the procedure. Which nursing statement would provide the best encouragement?

"Tell me about the delivery of your baby."

A nurse is providing instructions to the mother following delivery regarding care of the episiotomy site to prevent infection. Which statement by the mother indicates a need for further instructions?

"I will change the perineum pads three times a day."

A nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a neonate. The instructor determines that the student needs to research this procedure further if the student states:

"I will flush the eyes after instilling the ointment."

A nurse provides instructions to a breast-feeding mother who is experiencing breast engorgement about measures that will provide comfort. Which statement by the mother indicates an understanding of these measures?

"I will massage the breasts before feeding to stimulate let-down."

A nurse is instructing the mother of an infant about postcircumcision care. The nurse determines that teaching has been effective when the mother states which of the following?

"I will observe for signs of bleeding with each diaper change."

A nurse provides home care instructions to a postpartum client who had a cesarean delivery. Which statement by the client indicates an understanding of the instructions?

"If I develop a fever, I will call my doctor."

A nurse provides explanation to a client prescribed methylergonovine maleate (Methergine) in the immediate postpartum period regarding this medication. Which of the following statements made by the client demonstrates understanding of rationale for administration?

"It will help to prevent and control bleeding if it occurs."

A nurse is assigned to care for a client in the immediate postpartum period who received methylergonovine maleate (Methergine). The nurse determines the medication is effective when the client says:

"My afterpains are really strong."

The new breast-feeding mother has been seen in the clinic for the treatment of mastitis. The nurse knows that the mother needs further teaching when the mother states:

"My left breast is sore, so I will offer only my right breast frequently for breast-feeding."

A client asks the nurse why her newborn baby needs an injection of vitamin K. The nurse makes which statement to the client?

"Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding."

A postpartum client asks a nurse when she can resume sexual activity. The appropriate nursing response is which of the following?

"Sexual activity can be resumed in about 3 weeks once the episiotomy has healed and the lochia has stopped."

A concerned mother of a newborn with a cleft lip asks the nurse when the surgical repair will occur. The appropriate nursing response is which of the following?

"Surgical repair is usually around 6 to 12 weeks of age."

A nurse is caring for a newborn in the nursery and notes that the health care provider has documented that the child has gastroschisis. The parents ask the nurse about the treatment for the disorder. Which statement should the nurse make to the parents?

"The defect will be closed surgically after all of the contents have been returned to the abdominal cavity."

The pregnant client who is anemic tells the nurse that she is concerned about her baby's condition following delivery. The nurse makes which statement that will best address the client's concern?

"The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential.

A new mother is seen in the health care clinic 2 weeks after the birth of a healthy newborn. The mother says that she feels as though she has the flu and complains of fatigue and aching muscles. On further data collection the nurse notes a localized area of redness on the left breast, and the mother is diagnosed with mastitis. The mother asks the nurse how the condition occurs. The appropriate nursing response is which of the following?

"The infection can occur at anytime during breast-feeding."

After surgical evacuation and repair of a vaginal hematoma, a 3-day postpartum mother is discharged. The nurse determines that the mother needs further discharge instructions if the new mother states:

"The only medications that I will take are prenatal vitamins and stool softeners."

A nurse is caring for an infant with a diagnosis of hyperbilirubinemia. When explaining to the infant's mother the use of phototherapy, the nurse would make which statement to the mother?

"While undergoing phototherapy, your infant should wear an eye shield that is removed during feedings."

A nurse educates a mother about her newborn's diagnosis of fetal alcohol syndrome (FAS). Which statement by the mother provides the nurse with assurance that the mother understands this syndrome?

"Withdrawal symptoms include tremors, abnormal reflexes, and uncontrollable crying."

A stillborn was delivered in the birthing suite a few hours ago. After the birth, the family has remained together, holding and touching the baby. Which statement by the nurse should further assist the family in their initial period of grief?

"Would you like to hold your baby?"

A postpartum client who delivered at 32 weeks of gestation would like to breast-feed her preterm infant. At this time, the infant is receiving tube feedings only. What is the nurse's best response to the mother?

"You can begin pumping as soon as possible after delivery with an electric breast pump."

A postpartum client with gestational diabetes is scheduled for discharge. During the discharge, the client asks the nurse, "Do I have to worry about this diabetes anymore?" The nurse makes which response to the client?

"You will be at risk for developing gestational diabetes with your next pregnancy and developing overt diabetes mellitus."

It has been 12 hours since a client's delivery of a newborn. The nurse assesses the mother for the process of involution and documents that it is progressing normally when palpation of the client's fundus is noted at which level? Refer to figure.

1

The nurse is reinforcing measures regarding the care of the newborn with a mother. To bathe the newborn, the mother should be taught to:

Begin with the eyes and face

A nurse is providing nutritional counseling to a new mother who is breast-feeding her newborn. The nurse instructs the mother that her calorie intake needs to increase by approximately:

500 calories per day

A nurse is monitoring a new mother in the fourth stage of labor for signs of hemorrhage. Which of the following signs, if noted in the mother, would indicate an early sign of excessive blood loss and shock?

A increase in the pulse rate from 88 to 102 beats per minute

The nurse is reinforcing instructions to a new mother about cord care and how to monitor for infection. The nurse tells the mother that which of the following is a sign of infection?

A moist cord with discharge

A nurse's assignment is to visit a new mother at home who was recently discharged from the hospital. What finding would the nurse expect to note in a healthy breast-feeding mother and newborn?

A mother breast-feeding with the newborn in a tummy-to-tummy position every 3 to 4 hours without signs of cracked nipples; the baby demonstrates bursts of sucking followed by a pause and swallow

A nurse performs a blood glucose test on a newborn infant whose mother has diabetes mellitus and obtains a reading of 50 mg/dL. The nurse determines that this result indicates:

A normal level

A newborn is diagnosed with a hiatal hernia. The mother of the newborn asks the nurse to explain the diagnosis. The nurse bases the response on which of the following characteristics of this disorder?

A portion of the stomach protrudes through the esophageal hiatus of the diaphragm.

A nurse is assisting in developing a plan of care for a client preparing to breast-feed. In planning care, which factor is significant in teaching a client to breast-feed?

A positive nurse-client relationship

A nurse is preparing to teach a new mother to breast-feed. Which factor is important to promote an effective and positive learning experience?

A positive nurse-client relationship

A nurse is monitoring a client at risk for postpartum endometritis. Which observation noted during the first 24 hours after delivery may support this diagnosis?

Abdominal tenderness and chills

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn infant after admission to the nursery. The nurse suspects fetal alcohol syndrome (FAS) and is aware that which of the following additional signs would be consistent with FAS?

Abnormal palmar creases

A postpartum client is at high risk for infection. A goal has been developed that states, "The client will not develop an infection during her hospital stay." Which of the following data would support that the goal has been met?

Absence of fever

Which safety measures should be implemented at delivery and when working in the newborn nursery? Select all that apply.

Adhere to standard precautions during delivery and in the nursery. Place an identification bracelet on the infant only after the initial bath is completed in the nursery. Instruct the parents to not release their newborn infant to anyone wearing improper identification. Fingerprint the mother and footprint the infant on the identification card prior to removing the infant from the delivery room.

Choose the safety measures that should be implemented when working in the newborn nursery. Select all that apply.

Adhere to standard precautions. The parents should be instructed to not release their infant to anyone wearing improper identification. The mother should be fingerprinted and the infant should be footprinted on the identification card before removing the infant from the delivery room.

The goal for the postpartum client with thrombophlebitis is to prevent the complication of pulmonary embolism. In planning care to assist in meeting this goal, the nurse should:

Administer anticoagulants as prescribed.

A nurse in the postpartum unit notes that the result of a rubella titer drawn on a postpartum client during the antepartum period is 1:8. Which of the following would the nurse anticipate to be prescribed by the health care provider?

Administration of a subcutaneous rubella virus vaccine

A client had a cesarean delivery with a low transverse uterine incision. The nurse explains the benefits of this type of incision to the client, knowing that this type of incision:

Allows a vaginal birth after cesarean (VBAC) to be possible in a subsequent pregnancy

A nurse in a postpartum unit identifies which client as being at risk for developing endometritis following delivery?

An adolescent experiencing an emergency cesarean delivery for fetal distress

A nurse is assisting in providing a class to new mothers on newborn care. In teaching cord care, the nurse makes which suggestion to the new mothers?

Apply alcohol to the cord, ensuring that all areas around the cord are cleaned two or three times a day.

A nurse is assisting in caring for a newborn whose mother is Rh negative. In planning the newborn's care, it would be important for the nurse to:

Ask about the newborn's blood type and direct Coombs'.

A nurse is preparing to assist in performing a fundal assessment on a postpartum client. The nurse understands that the initial nursing action when performing this assessment is which of the following?

Ask the client to urinate and empty her bladder.

A nurse is performing a postpartum fundal assessment on a client 6 hours after delivery. The nurse finds the fundus above the umbilicus and displaced to the right. Which intervention should the nurse do first?

Assist the client to the bathroom to void and then reassess the fundus.

A delivery room nurse performs an assessment on a mother who just delivered a healthy newborn infant. The nurse checks the uterine fundus, expecting to note that it is positioned:

At the level of the umbilicus

After delivery, the nurse checks the height of the uterine fundus. The nurse expects that the position of the fundus would most likely be noted:

At the level of the umbilicus

A postpartum client asks the nurse when she may resume sexual activity. The nurse tells the client that sexual activity may:

Be resumed in about 3 weeks when the episiotomy has healed and the lochia has stopped

A client who is breast-feeding her newborn infant is experiencing nipple soreness. To relieve the soreness, the nurse suggests that the client:

Begin feeding on the less sore nipple.

Rho(D) immune globulin (RhoGAM) is prescribed for a woman after the delivery of a newborn infant, and the nurse provides information to the woman about the purpose of the medication. The nurse determines that the woman understands the purpose of the medication if the woman states that it will protect her next baby from which of the following?

Being affected by Rh incompatibility

A nurse is assigned to care for a client 1 hour after delivery. The nurse palpates a firm, uterine fundus 2 cm above the umbilicus and displaced to the right. The nurse recognizes that this finding may indicate:

Bladder distention

Methylergonovine (Methergine) is prescribed for a woman to treat postpartum hemorrhage. Before the administration of methylergonovine, the priority nursing action is to check the:

Blood Pressure

The nurse is caring for a postterm neonate immediately after admission to the nursery. The priority nursing action would be to monitor:

Blood glucose levels

A new mother attempting breast-feeding for the first time has developed mastitis. She states, "My breasts look terrible and I think that I will stop breast-feeding." The nurse plans care, knowing that the client's statement relates to:

Body image

A nurse discusses infant feeding options with a client following a vaginal delivery of a 6-pound full-term infant. The client has been diagnosed with human immunodeficiency virus (HIV) HIV. What is the appropriate method of feeding for this client?

Bottle-feeding with a tolerated formula

She should alternately contract and relax the muscles of the perineal area.

Bounding radial pulses and absent or weak femoral and pedal pulses

A nurse discovers an unresponsive breathing newborn infant. To assess circulatory status, the nurse should palpate which arterial pulse area?

Brachial

A nurse is assigned to care for a client in the immediate postpartum period who received epidural anesthesia for delivery, and the nurse monitors the client for complications. Which of the following would most likely indicate a hematoma?

Changes in viral signs

A nurse is caring for a 3-hour-old infant and notes that the infant has not eaten since birth, is jittery, and has a weak cry. The mother states that she can't get the baby to eat. What action should the nurse take first?

Check the blood glucose level.

A nurse is caring for a client during the immediate recovery phase or fourth stage of labor. The nurse's important action at this time is to:

Check the uterine fundus and lochia.

A nurse is collecting data on a postpartum client and performs which best intervention when checking for thrombophlebitis in the legs?

Checks the calf areas for redness or swelling

A pregnant client experienced a uterine rupture with subsequent fetal death. After ensuring that the client is physiologically stable, the nurse takes which approach as the best first step to support the client psychologically?

Collect data regarding how the client perceived the event.

A nurse is caring for a woman who is being treated with antibiotics for mastitis. The nurse reinforces instructions and tells the woman to:

Complete the entire antibiotic regimen.

A nurse is collecting data on a newborn infant with a diagnosis of a hiatal hernia. Which finding would the nurse expect to note in the infant?

Coughing, wheezing, and short periods of apnea

A client arrives to the postpartum unit following the delivery of her newborn premature infant. On data collection, the nurse notes that the client is shaking uncontrollably. Which of the following nursing actions is appropriate?

Covering her with a warm blanket

A nursing instructor is observing a nursing student caring for a newborn with a diagnosis of bladder exstrophy. The nursing student provides appropriate care to the infant by:

Covering the bladder with a sterile, nonadhering moist dressing

A nurse is caring for a neonate born to a mother who is addicted to drugs. The nurse expects to observe which of the following while caring for the neonate?

Cries incessantly

A postpartum nurse is collecting data from a client who delivered a viable newborn 2 hours ago. The nurse palpates the fundus and notes the character of the lochia. Which characteristic of the lochia would the nurse expect to note at this time?

Dark red lochia

A nurse is caring for a newborn following circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which of the following nursing actions would be appropriate?

Document the findings.

A nurse is changing the diaper of a 1-day-old, full-term female newborn and notes that the genitalia are red and swollen and that a thick white mucoid vaginal discharge is present. Based on these findings, the nurse determines that the best action would be to:

Document the findings.

An 8-day-old infant is irritable, has a high-pitched persistent cry, and a temperature of 99.4° F. The infant is also tachypneic and diaphoretic, continues to lose weight, and is hyperactive to environmental stimuli. The nurse determines that these behaviors may be consistent with:

Drug withdrawl

After birth, the nurse prevents hypothermia as a result of evaporation in the newborn by:

Drying the baby with a warm blanket

A nurse suspects her client has a pulmonary embolism when the client exhibits which of these signs and symptoms?

Dyspnea, tachypnea, and tachycardia

A nurse is reviewing the record of a newborn infant and notes that the health care provider has documented the presence of a cephalhematoma. Based on this documentation, the nurse expects to observe which of the following on data collection of the infant?

Edema caused from bleeding below the brain's periosteum

A postpartum client has lost 700 mL of blood. The vital signs indicate hypovolemia and the uterus remains atonic in spite of treatment. The nurse assisting in caring for the client understands the treatment that is necessary in this situation and prepares the client for:

Emergency surgery

A nurse is adding to a plan of care for a postpartum client. Which intervention will promote parent-infant bonding?

Encourage her to hold the infant even when the infant is crying.

A postpartum nurse obtains the vital signs on a mother who delivered a healthy newborn infant 2 hours ago. The mother's temperature is 100° F (38° C). The initial nursing action would be to:

Encourage oral fluid intake.

A nurse is assigned to care for a client admitted to the postpartum unit following delivery of a full-term healthy infant. The nurse checks the mother's temperature and notes that it is 100.4° F (38° C). Which nursing action would be appropriate?

Encourage oral fluids.

A nurse is assisting in caring for a newborn with respiratory distress syndrome. Which initial action should the nurse plan to best facilitate bonding between the newborn and parents?

Encourage the parents to touch their newborn.

A nurse who is caring for a postpartum mother being tested for endometritis notes that the client has little interest in caring for her infant. What intervention would best facilitate the client's participation in infant care?

Encouraging the client to take pain medication as prescribed

A nursing student is preparing to instill a medication into the eyes of a newborn as a preventive measure against ophthalmia neonatorum. The nursing instructor asks the student to identify the medication for the prophylaxis of ophthalmia neonatorum and gonococcal infection. The student correctly replies by telling the instructor that this medication is:

Erythromycin

A nurse in the delivery room is caring for a newborn delivered 10 minutes ago. The nurse assists to prepare which medications that will be prescribed to be given within the first hour of life? Select all that apply.

Erythromycin eye drops Phytonadione (Vitamin K)

A nurse is preparing to care for a woman in the immediate postpartum period who has just delivered a healthy newborn. The nurse plans to take the woman's vital signs:

Every 15 minutes for the first 2 hours

While a client is holding and talking to her newborn immediately following delivery, she begins to cry. The nurse interprets this behavior as indicating the client is:

Experiencing a normal response to birth

A nurse is caring for a client with placenta previa who is at high risk for infection and hemorrhage, as a result of this condition. The nurse plans care based on what information related to the condition?

Fewer muscle fibers in the lower segment of the uterus will result in poor contractions.

A nurse is assisting in preparing a plan of care for a client who just delivered a dead fetus. The appropriate initial intervention in meeting the emotional needs of the client and her spouse is which of the following?

Gather data from the client and spouse about the perception of the event.

A nurse enters a new mother's room and finds that the mother is crying and that the infant is undressed on the bed in front of the mother. The mother looks at the nurse and says, "I can't even dress this baby!" After reassuring the client, the nurse determines that the appropriate nursing action would be to:

Have the mother place the infant in the bassinet and assist the mother in dressing the baby

A nurse is planning for a nursery room admission of a large-for-gestational-age (LGA) infant. In getting ready to care for this infant, the nurse prepares equipment for which diagnostic test?

Heelstick blood glucose

A nurse is caring for a postpartum client who is being treated for thrombophlebitis. The client is receiving an anticoagulant by intravenous infusion. The nurse monitors for adverse effects of the anticoagulant by checking the client for:

Hematuria, ecchymosis, and epistaxis

When the client has been given instructions about postoperative complications following cesarean delivery, the nurse interprets that the client requires clarification of the information when the client identifies which situation as a reason to notify her health care provider?

Her temperature is 99° F.

A nurse is caring for a client who had a cesarean section to deliver a nonviable fetus as a result of abruptio placentae. The client develops signs of disseminated intravascular coagulopathy (DIC). The spouse asks the nurse what is happening, and the nurse explains the condition. The spouse becomes upset and says to the nurse, "I lost my baby and now my wife! What am I going to do?" Which of the following appropriately describes the situation?

Hopelessness related to loss of the baby and illness of the spouse

In formulating the plan of care, which problem is most important to address for a postpartum client who has expressed concerns about not knowing how to care for her newborn?

Lack of knowledge regarding ability to care for the newborn

A nurse is caring for a newborn diagnosed with hyperbilirubinemia. Which of the following actions is recommended for a newborn who is being breast-fed when diagnosed with hyperbilirubinemia?

Increase the frequency of breast-feeding.

A postpartum nurse is providing instructions to the mother of a breast-fed newborn who has hyperbilirubinemia. Which of the following instructions would the nurse provide to the mother?

Increase the frequency of the breast-feeding.

A nurse is reviewing the procedure for vitamin K injection in a newborn. Which information is included in the procedure?

Inject into skin that has been cleansed and allowed to have alcohol dry on the puncture site for 1 minute.

A nurse is reviewing the procedure for vitamin K injection in the newborn with a nursing student. Which information would the nurse provide to the student?

Inject into skin that has been cleansed with alcohol.

A nurse is collecting data on a client who is 6 hours postpartum following delivery of a full-term healthy newborn. The client tells the nurse that she feels faint and dizzy. Which nursing action would be appropriate?

Instruct the mother to request help when getting out of bed.

A nurse is assisting in administering beractant (Survanta) to a premature infant who has respiratory distress syndrome. The nurse understands that the medication will be administered by which of the following routes?

Intratracheal

A nurse is monitoring a newborn who was born to a drug-addicted mother. Which of the following findings would the nurse expect to note during data collection for this newborn? Select all that apply.

Is irritable Is difficult to console Cries incessantly Hyperextends and postures

A nurse observes slight facial jaundice in a 2-day-old full-term neonate. The nurse interprets this finding using which of the following guidelines?

Jaundice is visible on the skin of a neonate at bilirubin levels from 4 to 6 mg/dL, which are not abnormal in a 2-day-old neonate.

The nurse is assisting with caring for a postpartum client who is experiencing uterine hemorrhage. When planning to meet the psychosocial needs of the client, the nurse would:

Keep the client and her family members informed of her progress.

A client has had a midline episiotomy. In relation to clients with other types of episiotomies, the nurse anticipates that the client will generally experience:

Less pain

A woman with type 1 diabetes mellitus is in labor. Based on the knowledge of insulin and diabetes and pregnancy, the nurse will be prepared to care for a newborn infant who is likely to have which complication?

Macrosomia

The nurse is assigned to assist with caring for a neonate born to a mother with acquired immunodeficiency syndrome (AIDS). The nurse understands that which of the following should be included in the plan of care?

Maintain standard precautions at all times while caring for the neonate.

A nurse is assisting in developing a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse anticipates that which of the following interventions should be included in the plan of care? Select all that apply.

Maintaining bed rest Elevating the affected extremity Applying warm compresses to the affected area as prescribed

A mother is breast-feeding her newborn baby and experiences breast engorgement. The nurse encourages the mother to do which of the following to provide relief of the engorgement?

Massage the breasts before feeding to stimulate let-down.

A nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term neonate admitted to the newborn nursery. The nurse determines that which of the following additional sign(s) would be consistent with fetal alcohol syndrome (FAS)?

Microcephaly and increased respiratory effort

A nurse is caring for a neonate with fetal alcohol syndrome (FAS). The nurse includes which priority intervention in the plan of care for this newborn?

Monitor neonate response to feedings and the weight gain pattern.

The nurse is preparing to care for a newborn who is receiving phototherapy. Choose the measures that would be implemented. Select all that apply.

Monitor the skin temperature closely. Reposition the newborn every 2 hours. Cover the newborn's eyes with shields or patche

A nurse is assisting in developing a plan of care for a newborn infant with spina bifida (myelomeningocele type). The nurse includes data collection measures in the plan to monitor for increased intracranial pressure (ICP). Which action will best detect the presence of an increase in ICP?

Monitoring the anterior fontanel for bulging

Epidural analgesia is administered to a woman for pain relief after a cesarean birth. The nurse assigned to care for the woman ensures that which medication is readily available if respiratory depression occurs?

Naloxone (Narcan)

A nurse is monitoring a newborn infant who was circumcised. The nurse notes that the infant has a temperature of 100.6° F and that the dressing at the circumcised area is saturated with a foul-smelling drainage. The priority nursing action is to:

Notify RN

A nurse is bathing a neonate and notices small dark tufts of fine hair on the neonate's lower back. Based on this observation, the nurse should take which action?

Notify the health care provider of the finding.

A nurse is caring for a newborn whose mother had an elevated temperature during a prolonged labor. Which intervention(s) would be important to include in the newborn's plan of care?

Observe vital signs and central nervous system status frequently during the first 2 days.

After a newborn infant undergoes circumcision, which of the following would the nurse include in the post-procedure plan of care?

Observing for bleeding and monitoring for pain

A nurse is admitting a newborn infant to the nursery and notes that the health care provider has documented that the newborn has an omphalocele. The nurse collects data, knowing that in this condition, the viscera are:

Outside of the abdominal cavity but covered with a translucent sac

A postpartum nurse is about to reinforce discharge instructions to a postpartum client who delivered a healthy newborn infant. The occurrence of which event should be reported to the health care provider?

Pain, redness, or swelling in the breasts

A nurse is assisting in collecting data on a large-for-gestational age (LGA) newborn. Which technique does the nurse anticipate will be used to check for evidence of birth trauma?

Palpating the clavicles for a fracture

Methylergonovine (Methergine) is prescribed for a client with postpartum hemorrhage. Before administering the medication, a nurse contacts the health care provider who prescribed the medication if which of the following conditions is documented in the client's medical history?

Peripheral vascular disease

A mother is breast-feeding her newborn infant. The mother complains to the nurse that she is experiencing severe nipple soreness. The nurse should provide which of the following suggestions to the client?

Position the newborn infant with the ear, shoulder, and hip in straight alignment and with the baby's stomach against the mother's.

A nurse is caring for the postpartum client who is diagnosed with a low-lying placenta. The nurse monitors the client carefully for which complication?

Postpartum hemorrhage

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

Prepare an ice pack for application to the area.

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

Prepare the client for surgery.

A client in the postpartum unit complains of sudden, sharp chest pain. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. The initial nursing action would be which of the following?

Prepare to administer oxygen at 8 to 10 L by tight face mask.

The nurse administers erythromycin ointment (0.5%) to the newborn's eyes, and the mother asks the nurse why this is done. The nurse tells the client that this is routinely done to:

Prevent ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection.

a nurse is conducting a prenatal session with a group of expectant parents. The nurse tells the parents that the primary hormone that stimulates the secretion of milk is:

Prolactin

A postpartum nurse reinforces information provided to a new mother following a vaginal delivery regarding a sitz bath. The nurse determines that the client understands the purpose of the sitz bath when the client states that it will:

Promote healing of the perineum.

A new mother is attempting to breast-feed for the first time. The nurse notices that the client has inverted nipples. What nursing action can the nurse take to assist the client in breast-feeding the newborn?

Provide breast shells and assist the mother with using a breast pump before each feeding to make the nipples easier for the newborn to grasp.

A nurse is checking lochia discharge in a woman in the immediate postpartum period and notes that the lochia is bright red and contains some small clots. The nurse determines that this finding:

is normal

A neonate has just been circumcised. The nurse would expect the surgical site to appear:

Reddened, with a small amount of bloody drainage

A nurse receives a report at the beginning of the shift regarding a client with an intrauterine fetal demise. Which of the following would the nurse expect to note when collecting data on the client?

Regression of pregnancy symptoms and absence of fetal heart tones

A client is admitted to the labor and delivery suite with an intrauterine fetal demise. A nurse determines that the discussion with the parents was effective in preparing them for the delivery when the parents:

Request to hold the infant following delivery

A 45-year-old woman delivered her first baby by cesarean section 5 days ago. The postpartum recovery has been complicated by thrombophlebitis in her left leg. She cries frequently and requests to have her newborn infant stay in the nursery. The nurse recognizes that the mother may have intensified "postpartum blues" because she is:

Required to stay on bedrest

A nurse reviews the arterial blood gas report on a newborn with respiratory distress syndrome (RDS) who was recently weaned from the ventilator and placed in an oxygen hood at 50% oxygen. The results indicate a pH 7.25, PaO2 80 mm Hg, PaCO2 50 mm Hg, and HCO 24 mEq. The nurse evaluates the blood gas report as indicating:

Respiratory acidosis

A client experiences subinvolution during the puerperium. The nurse recalls that which of the following are the most common causes for this occurrence?

Retained placental fragments and infections

A postpartum client suspected of having an infection is informed that she will be unable to have the newborn present in the room with her. The nurse plans care, knowing that which of the following is the highest priority problem at this time?

Risk of ineffective bonding between the mother and newborn

As a part of discharge teaching, a new mother has been provided with instructions about how to perform postpartum exercises. The nurse determines that the client understands the instructions when she states that:

She should alternately contract and relax the muscles of the perineal area.

A nurse observes the client following delivery for normal maternal physiological changes that are anticipated. The nurse would document which expected changes?

Slowed pulse rate and elevated blood pressure

Oxytocin (Pitocin) is prescribed to be administered intravenously to a client after a cesarean delivery. The nurse understands that the action of the medication is to:

Stimulate the uterus to contract, thus reducing possible blood loss.

After a precipitate delivery, a nurse notes that a new mother is passive and only touches her newborn briefly with her fingertips. The nurse would do which of the following first to help the woman process what has happened?

Support the mother no matter what her reaction to the newborn is.

A nurse in the newborn nursery is assisting in monitoring a preterm newborn for respiratory distress syndrome (RDS). Which of the following findings, if noted in the newborn, would alert the nurse to the possibility of this syndrome?

Tachypnea and retractions

A nurse is monitoring a preterm newborn for respiratory distress syndrome (RDS). Which findings in the newborn should alert the nurse to the possibility of this syndrome?

Tachypnea and retractions

A nurse is collecting data on a newborn admitted to the nursery with a diagnosis of subdural hematoma after a difficult vaginal delivery. The nurse demonstrates an understanding of the major symptoms associated with subdural hematoma when:

Testing for equality of extremities when stimulating reflexes

A postpartum nurse is caring for a mother following delivery of a newborn infant. The nurse performs a perineal assessment on the mother and notes a trickle of bright red blood coming from the perineum. The nurse checks the mother's fundus and notes that it is firm. On review of the mother's record, the nurse also notes that an episiotomy was performed. Based on this information, the nurse determines that:

The bright red bleeding is abnormal and should be reported.

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

The bright red bleeding is abnormal and should be reported.

A nurse is reviewing the criteria for early discharge of a newborn infant with a new mother. Which of the following if noted in the infant indicate that the criterion for early discharge has not been met?

The infant has evidence of significant jaundice.

A nurse is preparing to administer an injection of vitamin K to a newborn. When administering the injection, the nurse would select which injection site?

The lateral aspect of the middle third of the vastus lateralis muscle

A postpartum nurse has reinforced instructions to a new mother on how to bathe her newborn. The nurse demonstrates the procedure to the mother and on the following day asks the mother to perform the procedure. Which of the following observations, if made by the nurse, indicates that the mother is performing the procedure correctly?

The mother begins to wash the newborn by starting with the eyes and face.

A nurse is monitoring a new mother for signs of postpartum depression. Which of the following, if noted in the new mother, would indicate the need for further data collection related to this form of depression?

The mother constantly complains of tiredness and fatigue.

Which of the following if noted in the new mother indicates the need for further data collection by the nurse for signs of postpartum depression?

The mother constantly complains of tiredness and fatigue.

A nurse is reviewing the health care record of a newborn admitted to the nursery; the newborn is suspected of having an imperforate anus. The nurse understands that which documented finding is unassociated with this disorder?

The passage of bloody mucus stool

A nurse is checking the lochia discharge on a 1-day postpartum woman. The nurse notes that the lochia is red and has a foul odor. The nurse determines that this finding indicates:

The presence of infection

The nurse is assigned to care for the client during the postpartum period. The client asks the nurse what the term involution means. The nurse responds to the client, knowing that involution is:

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

In caring for a preterm newborn's skin, the nurse must understand the special characteristics that exist. These include a:

Thin and gelatinous skin with decreased amounts of subcutaneous fat and an open posture

A nurse in the postpartum unit is assigned to care for a client who delivered a full-term, healthy baby. The nurse receives the report and is told that the mother had lost 500 mL of blood during the delivery. When checking the vital signs, the nurse notes that the woman's pulse is 90 beats per minute and is weak and thready. This finding would indicate which of the following to the nurse?

This may be a sign of hemorrhage or shock.

A postpartum client with mastitis in the right breast complains that the breast is too sore for her to breast-feed her infant. The nurse tells the client:

To breast-feed from the left breast and gently pump the right breast

The mother of a newborn calls the clinic and reports to the nurse that when she was cleansing the newborn's umbilical cord, the cord was moist and discharge was noted. The appropriate nursing instruction to the mother is which of the following?

To bring the infant to the clinic

A nurse in the newborn nursery is collecting data on a neonate who was born of a mother addicted to cocaine. Which of the following would the nurse expect to note in the neonate? Select all that apply.

Tremors Irritability Hypertension Exaggerated startle reflex

A nurse is assisting in developing a plan of care for a client in the fourth stage of labor who received an epidural. Which of the following problems is most likely to occur during this stage?

Urinary retention caused by the loss of sensation to void and rapid bladder filling

Oxytocin (Pitocin) is administered to a client following the delivery of the placenta. The nurse assisting in caring for the client monitors for an effective response from the medication by monitoring for:

Uterine contractions

A nurse is performing an assessment on a 2-day postpartum mother. The mother complains of severe pain and an intense feeling of swelling and pressure in the vulvar area. After hearing these complaints, the nurse specifically checks the client's:

Vulva for a hematoma

A nurse in the delivery room is assisting with the delivery of a newborn. The nurse prepares to prevent heat loss in the newborn due to conduction by:

Warming the crib pad before placing the newborn in the crib

A nurse has instructed a postpartum client who is hepatitis B positive how to safely bottle-feed her newborn to prevent the transmission of the infection. Which action by the client indicates an understanding of this procedure?

Washes and dries her hands before feeding

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

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

A postpartum nurse is monitoring the amount of lochial flow in a client following delivery. Which activity is a part of the method to accurately determine the amount of flow for documentation purposes?

Weighing the perineal pad before and after use

A nurse reviews the results of a bilirubin level on a 2-day-old jaundiced term newborn. The results indicate a total bilirubin level of 7.2 mg/dL. The newborn's mother verbalizes concern over the bilirubin results. After interpreting the bilirubin results, the nurse's response would include an explanation that the bilirubin level is:

Within acceptable ranges

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

ambulate frequently

A nurse in the postpartum 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:

eight pads a day

Breast-feeding instructions for the postpartum mother should include avoidance of soaps on the nipples, frequent changing of breast pads, intermittent exposure of nipples to air, and handwashing before handling the breast and before breast-feeding. The nurse understands that these measures are specific to the prevention of:

mastatis

When performing a postpartum assessment on a client, the licensed practical nurse (LPN) notes clots in the lochia. The LPN examines the clots and notes that they are larger than 1 cm. Which of the following nursing actions is appropriate?

notify rn

A nurse is caring for a woman who has delivered a baby after a pregnancy with a placenta previa. The nurse monitors the client frequently, knowing that the client is at risk for:

postpartum hemorrhage

The nurse palpates the fundus and checks the character of the lochia of a postpartum client who is in the fourth stage of labor. The nurse expects the lochia to be:

red