Ch 12, 13, 15 OB NCLEX
What suggestions does the nurse give the mother to keep that baby safe regarding cold stress after discharge? ALL THAT APPLY A. Keep the baby wrapped in a warm blanket B. Perform daily bath in a warm location C. Position baby away from the vents and drafts D. Place a stocking cap on the neonates head E change wet clothing immediatly
1,3,4,5, Babies do not need daily baths. undressing and bathing will cause heat loss d/t evaporation
Which of the following nursing actions are directed at promoting bonding? (select all that apply) A. Providing opportunity for parents to hold their newborn as soon as possible following birth B. Providing opportunities for the couple to talk about their birth experience and about beoming parents C. Promoting rest and comfort by keeping the newborn in the nursery at night D. Providing positive comments to parents regarding their interactions with their newborn
A, B,D
The nuse is providing teaching to a pt who is breastfeeding a newborn. The pt expresses interest in maintaining a healthy nutritional status for her and the baby. Which information does the nurse present to meet the pts needs? ALL THAT APPLY A. Increase caloric intake by 500 to 1000 per day B. Drink 2-3L of fluid each day C. Abstain from the intake of alcohol D. Eat fresh fruits and veg E. avoid the intake of processed food
A,B, . No evidence an occasional alcoholic drink is harmful, Some fruits and veg may cause the baby to have gas or loose stools, the mother should be conscious of consuming a healthy balanced diet.
The nurse is performing a uterus assessment on a pt who is 20 hrs postpartum. The nurse finds the fundus of the uterus to be soft and boggy. In addition the uterus is disiplaces to the left and moderate bleeding is noted If the uterus does not respond to uterine massage, which actions does the nurse implement? ALL THAT APPLY A. Assist the pt to the bathroom to void B. Reassess to determine response to treatment C. Administer oxytocin as prescribed D. Place an emergency call to HCP E. Make the pt NPO for sx
A,B,C,E
During the 4th stage of labor which actions by the nurse will promote parent-newborn bonding? ALL THAT APPLY A. Delay administration of eye ointment until parents have held newborn B. Stay close to the couple and teh neonate in case of emergency C. Space out necessary assessments to prevent prolonged interruptions D. Initiate skin to skin contact with a warm blanket over neonate and parent E. Explain expected neonatal charactericts such as molding, milia and lanugo
A,D,E
The nurse is providing care for a neonate during the 4th stage of labor. Which action does the nurse take in this stage. A. Dry neonate immmediatly B. Complete neonate assessment within 1 hr C. Obtain neonate blood glucose levels D. Perform Apgar screening until scores are 7
A. 4th stage is birth to 4 hours postpartum. Nurse will dry immediately to aid with thermoregulation
The multiparous pt reports severe uterine cramps the first day after a vaginal delivery. The nurse is aware the pt is breastfeeding and assciates the pts pain primarily with which occurrence? A. An increase in oxytocin released to the newborn suckling B. The presence of intense afterbirth pains related to multiparity C. An expected response to the daily administration of oxytocin D. The efforts of the uterus to return to a prepregnancy condition
A. Although pains can be related to multiparity, in this situation the nurse recognizes that the pains are assoc with the release of oxytocin
A pt delivers a term neonate and expresses concerns about the reason for giving the neonate an injection. Which information from the nurse is accurate. A. neonates will hemorrhage without vitamin K B. Vitamin K is needed to activate clotting factors C. Mothers are unable to supply vitamin K to the fetus D. Breastfeeding is an excellent sourse of vitamin K
B
During a psotpartum assessment the nurse notes that the uterus is midline and boggy. The immediate action is: A. notify pts provider B. Massage fundus until firm and reevaluate in 30 min C. Give oxytocin as ordered D. Assist the pt to the bathroom and ask her to void
B
A woman is 2 days postpartum from a normal vaginal delivery over an intact perineum of a 300-gram baby. Where would the nurse expect to palpate the clients fundus? a. At the umbilicus b. 2 cm below umbilicus c. 2cm above the symphysis d. At the symphysis
B After 24 hours, fundus is 1cm below umbilicus per day
The nurse assesses that a full-term neonates temperature is 36.2C. The first nursing action is to: a. Turn up the heat in the room. b. Place the neonate on the mothers chest with a warm blanket over the mother and baby. c. Take the neonate to the nursery and place in a radiant warmer. d. Notify the neonates primary provider.
B Skin to skin contact along with use of warm blanket is the best intervention with mild temperature decrease in neonate
The woman who gave birth to 2nd child informs the nurse that she is bleeding more than her previous birth experience. The initial nursing action is to: A. Explain that this is normal for 2nd time moms B. Assess the location and firmness of the fundus C. Change her pad and return in 1 hr and reassess D. Give her 10 Units of oxytocin as per standing order
B. Assess uterine atony or displaces uterus from full bladder
The nurse is observing a new mother interact with her baby and notices the mother holding the baby close to her body. However, the nurse also notices that the mother does not hold the baby in the enface positon. Which question is the most appropriate for then nurse to ask? A. Can I help you with a nice position in which to hold our baby? B. Can you tell me about your familes beliefs with a new baby? C. Is there some reason I have not seen you look into your baby's eyes? D. Your baby is so expressive, have you looked into his eyes yet?
B. Cultural information may be influencing the mothers interaction with the baby
The nurse is collecting the urine of a postpartum pt who is passing large clots. For which reason does the nurse examine the large collected clots? A. To validate the presence of clotting B. To determine the presence of tissue C. To obtain an accurate description D. To document the number of clots
B. Presence of tissue could indicate retained placenta tissue which can lead to excessive bleeding
The nurse is preparing a postpartum pt for discharge. Which pt teaching is most important for the nurse to provide? A. s/s of uterine infection B. s/s of secondary hemorrhage C. s/s of postpartum depression D. s/s of boggy uterus
B. Secondary hemorrhage often occurs after discharge and pt needs to report abnormal amts of bleeding
Which pt reported sysmptms cause the nurse to most concern 8 days following a vaginal delivery? A. Increased flow noticed with physical activity B. A description of the lochia as being red in color C. Discharge that is noted to have a fleshy odor D. Bleeding that is described as scant
B. The lochia during the period of 4-10 days should be serosa (pink or brown) Red is indicative of bleeding
The nurse notices a neonate born 45 min ago is unresponsive to external stimuli, and has a respiratory rate and heart rate beow normal range. Which action does the nurse take? A. Picks up the neonate and tries to get a response B. Allows the neonate to naturally continue deep sleep C. Asks another nurse to assist with reassessment D. Notifies the caregiver of the neonate's condition
B. This Deep sleep could last for about 2 hours
Which behavior does the nurse edentify as a demonstration of unidirectional bonding between a parent and infant? A. The parents respond to baby's cry B. The parents call the baby by name C. The baby responds to comforting measures D. The parents stiulate and entertain the baby
B. Using the baby's name is unidirectional bonding
When assessing apical rate of neonate, the stethescople whould be placed at the: A. 1st or 2nd intercostal space B. 2nd or 3rd intercostal space C. 3rd or 4th intercostal space D. 4th or 5th intercostal space
C
Which of the following clients is most likely to complain if afterbirth pains during her postpartum period? a. G1 P0, diagnosed with preclampsia b. G2 P0, group B streptococci in vagina c. G3 P2, gave birth to a 4100-gram baby d. G4 P1, diagnosed wit preterm labor
C a. this client is a primipara b. this client is a primipara c. This client is multipara and she delivered a macrosomic baby. She is likely to complain of sever afterbirth pain since she is multi paraous d. Altho patient is gravida 4, she is para 1 while client c is para 2. Nurse would not expect her to complain excessively of after birth pain compared to client c
The nurse is perfroming a postpartum assessment 30 min after a vaginal delivery. Which of the following actions indicated that the nurse is perfoming the assessement correctly? A. Nurse measures the fundal height in relation to the symphysis pubis B. Nurse monitors the clients central venous pressure C. Nurse assesses the clients perineum for edema and ecchymoses D. Nurse performs a sterile vaginal speculum exam
C.
The postpartum nurse is planning a home visit to a mother who delivered the baby 1 week ago. Which finding indicates to the nurse a possible problem with mother-infant bonding A. Mother is pleased to have the nurse visit her home and baby B. The baby's grandmother is present and involved with mother/baby care C. The mother focuses the visit on her physical recovery and concerns D. The baby's father is on "Paternity leave" and involved with the baby
C. After first 48 the mother moves into the "taking hold" phase when the mothers focus moves form self to infant.
The nurse is providing postpartum care to a pt 24 hrs after vaginal delivery. Which action does the nurse perform prior to assessing the pts uterus? A. Place the pt on the left side B. Assess the passage of lochia C. Ask the pt to void D. Administer a dose of oxytocin
C. An overdistended bladder can result in unterine displacement and atony
The nurse is providing care for a new mother durng a follow up 6 week after vaginal delivery. The mother begins to cry and reports difficulity with eating and sleeping. The nurse identifies post partum blues and cites which reason as the most likely cause? A. Fatigue related to "fussy" baby B. Frustration over physical appearance C. Changes in hormonal levels D. Stress r/t new mother role
C. Most likely cause is change in hormone levels
The nurse in a postpartum unit frequently teaches pts regarding breast care. Which teaching is most helpful to the breastfeeding pt. A. Run warm water over breasts while in the shower B. Wear a supportive bra 24 hrs a day C. Express milk by a breast pump or manually D. Take analgesics for brease pain mgmt.
C. This will help relieve breast engorgement
A woman on the day of discharge from the postpartum unit requests clean towels so she can take a shower, asks a number of questions regarding breastfeeding, and shares that she is nervous about taking her baby home and not being able to remember everything she has been taught. These are behmore independentaviors associates with: A. Bonding B. Taking in C. Taking hold D. Attachment
C. more independant and able to initiate self care. Interested about learning about the care of their baby.
A mother refused to allow her son to receive the vitamin K injection at birth. Which of the following signs or symptoms might the nurse observe in the baby as a result? a. Skin color is dusky. b. Vital signs are labile. c. Glucose levels are subnormal. d. Circumcision site oozes blood.
D May ooze blood due to lack of vitamin K, which is required for hepatic synthesis of blood coagulation factors
The nuse is providing post partum care for an adolescent mother and her family. Which factor is most important for the nurse to consider when planning teaching about neonatal care? A. the grandparents decided they want to be involved B. The parents need to discuss their expectations of each other C. The mother is determined the father should be involved D. Information shoud be presented on age-appropriate level
D.
The nurse is palpating the pts uterus 12 hours after a vaginal delivery. For which reason does the nurse place one hand just above the symphysis pubis? A. To prevent uterine prolapse B. To prevent uterine movement C. To prevent uterine hemmorrhage D. To prevent uterine inversion
D. Pregnancy stretches the ligaments that hold the uterus in place, and fundal pressure could result in uterine inversion
On day 4 following the birth of an average size baby, the nurse would expect the fundus to be at: A. 1cm below umbilicus B. 2cm below umbilicus C. 3 cm below umbilicus D. 4 cm below umbilicus
D. The uterus on average descents 1 cm per day