Chapter 21
When should discharge instruction, or the teaching plan that tells the woman what she needs to know to care for herself and her newborn, officially begin? A. At the time of admission to the nurses unit B. When the infant is presented to the mother at birth C. During the first visit with the physician in the unit D. When the take-home information packet is given to the couple
A. At the time of admission to the nurses unit
In many hospitals, new mothers are routinely presented with gift bags containing samples of infant formula. This practice is inconsistent with what? A. Baby Friendly Hospital Initiative B. Promotion of longer periods of breastfeeding C. Perception of being supportive to both bottle feeding and breastfeeding mothers D. Association with earlier cessation of breastfeeding
A. Baby Friendly Hospital Initiative
Many new mothers experience some type of nipple pain during the first weeks of initiating breastfeeding. Should this pain be severe or persistent, it may discourage or inhibit breastfeeding altogether. Which factors might contribute to this pain? (Select all that apply.) A. Improper feeding position B. Large-for-gestational age infant C. Fair skin D. Progesterone deficiency E. Flat or retracted nipples
A. Improper feeding position C. Fair skin E. Flat or retracted nipples
Rh immune globulin will be ordered postpartum if which situation occurs? A. Mother Rh, baby Rh+ B. Mother Rh, baby Rh C. Mother Rh+, baby Rh+ D. Mother Rh+, baby Rh
A. Mother Rh, baby Rh+
Which practices contribute to the prevention of postpartum infection? (Select all that apply) A. Not allowing the mother to walk barefoot at the hospital B. Educating the client to wipe from back to front after voiding C. Having staff members with conditions such as strep throat, conjunctivitis, and diarrhea stay at home D. Instructing the mother to change her perineal pad from front to back each time she voids or defecates E. Not permitting visitors with cough or colds to enter the postpartum unit
A. Not allowing the mother to walk barefoot at the hospital C. Having staff members with conditions such as strep throat, conjunctivitis, and diarrhea stay at home D. Instructing the mother to change her perineal pad from front to back each time she voids or defecates
If a woman is at risk for thrombus and is not ready to ambulate, which nursing intervention would the nurse use? (Select all that apply) A. Putting her in antiembolic stockings (thromboembolic deterrent [TED] hose) and/or sequential compression device (SCD) boots. B. Having her flex, extend, and rotate her feet, ankles, and legs. C. Having her sit in a chair. D. Immediately notifying the physician if a positive Homans' sign occurs. E. Promoting bed rest
A. Putting her in antiembolic stockings (thromboembolic deterrent [TED] hose) and/or sequential compression device (SCD) boots. B. Having her flex, extend, and rotate her feet, ankles, and legs. D. Immediately notifying the physician if a positive Homans' sign occurs.
Which physiologic factors are reliable indicators of impending shock from postpartum hemorrhage? (Select all that apply) A. Respirations B. Skin condition C. Blood pressure D. Level of consciousness E. Urinary output
A. Respirations B. Skin condition D. Level of consciousness E. Urinary output
The laboratory results for a postpartum woman are as follows: blood type, A; Rh status, positive; rubella titer, 1:8 (enzyme immunoassay [EIA] 0.8); hematocrit, 30%. How should the nurse best interpret these data? A. Rubella vaccine should be administered B. Blood transfusion is necessary C. Rh immune globulin is necessary within 72 hours of childbirth D. Kleihauer-Betke test should be performed
A. Rubella vaccine should be administered
Nurses play a critical role in educating parents regarding measures to prevent infant abduction. Which instructions contribute to infant safety and security? (Select all that apply) A. The mother should check the photo ID of any person who comes to her room. B. The baby should be carried in the parent's arms from the room to the nursery. C. Because of infant security systems, the baby can be left unattended in the patient's room. D. Parents should use caution when posting photos of their infant on the Internet. E. The mom should request that a second staff member verify the identity of any questionable person.
A. The mother should check the photo ID of any person who comes to her room. D. Parents should use caution when posting photos of their infant on the Internet. E. The mom should request that a second staff member verify the identity of any questionable person.
A primiparous woman is to be discharged from the hospital the following day with her infant girl. Which behavior indicates a need for further intervention by the nurse before the woman can be discharged? A. The woman is disinterested in learning about infant care B. The woman continues to hold and cuddle her infant after she has fed her C. The woman reads a magazine while her infant sleeps D. The woman changes her infants diaper and then shows the nurse the contents of the diaper
A. The woman is disinterested in learning about infant care
A hospital has a number of different perineal pads available for use. A nurse is observed soaking several of them and writing down what she sees. What goal is the nurse attempting to achieve by performing this practice? A. To improve the accuracy of blood loss estimation , which usually is subjective assessment B. To determine which pad is the best C. To demonstrate that other nurses usually underestimate blood loss D. To reveal to the nurse supervisor that one of them needs some time off
A. To improve the accuracy of blood loss estimation , which usually is subjective assessment
In providing support to a new mother who must return to full-time employment 6 weeks after a vaginal delivery, which action by the nurse is best? a. Allow her to express her positive and negative feelings freely. b. Reassure her that she'll get used to leaving her baby. c. Discuss child care arrangements with her. d. Allow her to solve the problem on her own.
ANS: A Allowing the patient to express feelings will provide positive support in her process of maternal adjustment. Simply reassuring the mother blocks further communication and belittles her feelings. Discussing child care arrangements should wait until she has expressed herself. She should be instrumental in solving the problem; however, allowing her time to express her feelings and talk the problem over will assist her in making this decision.
Which finding 12 hours after birth requires further assessment? a. The fundus is palpable two fingerbreadths above the umbilicus. b. The fundus is palpable at the level of the umbilicus. c. The fundus is palpable one fingerbreadth below the umbilicus. d. The fundus is palpable two fingerbreadths below the umbilicus.
ANS: A The fundus rises to the umbilicus after delivery and remains there for about 24 hours. A fundus that is above the umbilicus may indicate uterine atony or urinary retention. The nurse needs to make further assessments. The other findings are within normal limits for the time period.
A woman's chart indicates she has a second-degree laceration. When assessing this patient, the nurse plans to observe which of the following structures? (Select all that apply.) a. Vaginal mucosa b. Perineal skin c. Peritoneal muscle d. Anus e. Rectum
ANS: A, B, C A second-degree perineal laceration includes vaginal mucosa, perineal skin, and peritoneal muscle. A third-degree laceration involves the anus, while a fourth-degree laceration includes the rectum
The nurse assesses a woman's episiotomy or perineal laceration using the acronym REEDA. What factors does this include? (Select all that apply.) a. Redness b. Edema c. Approximation d. Depth e. Discharge
ANS: A, B, C, E The acronym REEDA indicates redness, edema, ecchymosis or bruising, discharge, and approximation. Depth is not a consideration with this acronym
When caring for a newly delivered woman, the nurse is aware that the best measure to prevent abdominal distention after a cesarean birth is a. rectal suppositories. b. early and frequent ambulation. c. tightening and relaxing abdominal muscles. d. providing carbonated beverages.
ANS: B Activity can aid the movement of accumulated gas in the gastrointestinal tract so early, and frequent ambulation is the best option. Rectal suppositories can be helpful after distention occurs but do not prevent it. Tightening and relaxing the abdominal muscles is not related. Carbonated beverages may increase distention.
To promote bonding and attachment immediately after delivery, what action by the nurse is most important? a. Allow the mother quiet time with her infant. b. Assist the mother in assuming an en face position with her newborn. c. Teach the mother about the concepts of bonding and attachment. d. Assist the mother in feeding her baby
ANS: B Assisting the mother in assuming an en face position with her newborn will support the bonding process. Quiet time with the infant is helpful but not as important as en face positioning. The mother has just delivered and is more focused on the infant; she will not be receptive to teaching at this time. This is a good time to initiate breastfeeding, but this is not as specific to bonding and attachment as the en face position.
A man calls the nurse's station stating that his wife, who delivered 2 days ago, is happy one minute and crying the next. The man says, "She was never like this before the baby was born" What response by the nurse is best? a. Tell him to ignore the mood swings, as they will go away. b. Reassure him that this behavior is normal. c. Advise him to get immediate psychological help for her. d. Instruct him in the signs, symptoms, and duration of postpartum blues.
ANS: B Before providing further instructions, inform family members of the fact that postpartum blues are a normal process to allay anxieties and increase receptiveness to learning. Telling him the mood swings will go away is belittling his concerns. Postpartum blues are a normal process that is short lived; no medical intervention is needed. Client teaching is important; however, his anxieties need to be allayed before he will be receptive to teaching
To assess fundal contraction 6 hours after cesarean delivery, the nurse should a. palpate forcefully through the abdominal dressing. b. gently palpate, applying the same technique used for vaginal deliveries. c. place hands on both sides of the abdomen and press downward. d. rely on assessment of lochial flow rather than palpating the fundus.
ANS: B Assessment of the fundus is the same for both vaginal and cesarean deliveries; however, palpation should be gentle due to increased discomfort caused by the uterine incision. Forceful palpation should never be used. The top of the fundus, not the sides, should be palpated and massaged. The fundus should be palpated and massaged to prevent bleeding
A nurse observes a mother on her first postpartum day sitting in bed while her newborn lies awake in the bassinet. What action by the nurse is best? a. Realize that this situation is perfectly acceptable. b. Offer to hand the baby to the woman. c. Hand the baby to the woman. d. Explain "taking in" to the woman.
ANS: C During the "taking-in" phase of maternal adaptation, in which the mother may be passive and dependent, the nurse should encourage bonding when the infant is in the quiet alert stage. This is done best by simply giving the baby to the mother. While acceptable, the nurse can still facilitate infant bonding. The woman is dependent and passive at this stage and may have difficulty making a decision so offering her the baby is not the best option. Women learn best in the taking-hold phase
What is the best way for the nurse to promote and support the maternal-infant bonding process? a. Help the mother identify her positive feelings toward the newborn. b. Encourage the mother to provide all newborn care. c. Assist the family with rooming-in. d. Return the newborn to the nursery during sleep periods.
ANS: C Close and frequent interaction between mother and infant, which is facilitated by rooming-in, is important in the bonding process. This is often referred to as the mother-baby care or couplet care. Having the mother express her feelings is important, but it is not the best way to promote bonding. The mother needs time to rest and recuperate; she should not be expected to do all of the care. The mother needs to observe the infant during all stages so she will be aware of what to expect when they go home.
If the patient's white blood cell (WBC) count is 25,000/mm3 on her second postpartum day, the nurse should a. tell the physician immediately. b. have the laboratory draw blood for reanalysis. c. recognize that this is an acceptable range at this point. d. begin antibiotic therapy immediately
ANS: C Marked leukocytosis occurs with WBC counts increasing to as high as 30,000/mm3 during labor and the immediate postpartum period. The WBC falls to normal within 6 days postpartum. No action is necessary
A 25-year-old gravida 1 para 1 who had an emergency cesarean birth 3 days ago is scheduled for discharge. As the nurse prepares her for discharge, she begins to cry. What action should the nurse take first? a. Assess her for pain. b. Point out how lucky she is to have a healthy baby. c. Explain that she is experiencing postpartum blues. d. Allow her time to express her feelings.
ANS: D Many women experience transient postpartum blues and need assistance in expressing their feelings. This condition affects 70% to 80% of new mothers. The nurse should allow time for the new mother to express herself. The nurse should not assume she is in pain at this point. Pointing out how lucky she is belittles her feelings. Patient teaching can be done later.
A new father states, ―I know nothing about babies,‖ but he seems to be interested in learning. What action by the nurse is best? a. Continue to observe his interaction with the newborn. b. Tell him when he does something wrong. c. Show no concern, as he will learn on his own. d. Include him in teaching sessions.
ANS: D The nurse must be sensitive to the father's needs and include him whenever possible. As fathers take on care new role, the nurse should praise every attempt even if his early care is awkward. It is important to note the bonding process of the mother and the father, but that does not satisfy the expressed needs of the father. He should be encouraged by pointing out the correct procedures he does. Criticizing him will discourage him. The nurse should be sure to include him in all teaching sessions
A nurse is observing a family. The mother is holding the baby she delivered less than 24 hours ago. Her husband is watching his wife and asking questions about newborn care. The 4-year-old brother is punching his mother on the back. What action by the nurse is best? a. Report the incident to the social services department. b. Advise the parents that the toddler needs to be reprimanded. c. Report to oncoming staff that the mother is not a good disciplinarian. d. Realize that this is a normal family adjusting to family change
ANS: D The observed behaviors are normal variations of families adjusting to change. The nurse could provide suggestions on managing the adjustments. There is no need to report this one incident. The child does not need to be reprimanded, however; when the family is receptive the nurse could provide anticipatory guidance for this situation and help them problem solve. The nurse should avoid labeling the parents.
A postpartum patient asks, "Will these stretch marks go away?" The nurse's best response is a. "They will fade and be gone by your 6-week checkup" b. "No, unfortunately they will never fade away" c. "Yes, eventually they will totally disappear" d. "They will fade to silvery lines but won't disappear completely"
ANS: D The stretch marks will fade to silvery lines but will not disappear completely. It is important to emphasize to the patient that this is normal
Which nursing action is most appropriate to correct a boggy uterus that is displaced above and to the right of the umbilicus? a. Notify the provider of an impending hemorrhage. b. Assess the blood pressure and pulse. c. Evaluate the lochia. d. Assist the patient in emptying her bladder.
ANS: D Urinary retention can cause overdistention of the urinary bladder, which lifts and displaces the uterus. Nursing actions need to be implemented before notifying the provider. Blood pressure, pulse, and lochia are important to assess, but first the nurse assesses the bladder so corrective action can be taken if needed
The nurse is instructing a group of new parents about normal newborn behavior. Which attendee's statement indicates that teaching was effective? 1. "My baby will be able to hear very well immediately after birth." 2. "My baby will have difficulty seeing me close up right after delivery." 3. "My baby should be discouraged from sucking on a pacifier if being bottle fed." 4. "My baby should be trained to breastfeed by being encouraged to suck on a pacifier before feedings."
Answer: 1 Explanation: 1. Newborns have very acute hearing immediately after birth. 2. The newborn is nearsighted and has best vision at a distance of 8 to 15 inches. 3. For bottle-fed infants, there is no reason to discourage nonnutritive sucking with a pacifier. 4. Pacifiers should be offered to breastfed infants only after breastfeeding is well established or during prolonged times away from the mother, or when stressful or painful procedures are required.
A telephone triage nurse gets a call from a postpartum client who is concerned about jaundice in a 37-hour-old newborn. What information should the nurse gather first? 1. Skin color 2. Fluid intake 3. Bilirubin level 4. Stool characteristics
Answer: 1 Explanation: 1. Yellow coloration of the skin and sclerae is a sign of physiologic jaundice that appears after the first 24 hours postnatally. Inspection of the skin would be the first step in assessing for jaundice. 2. Inadequate fluid intake can predispose an infant toward becoming jaundiced and is best determined by the number of wet diapers per day. 3. Skin color begins to appear yellow once the serum levels of bilirubin are about 4 to 6 mg/dL. 4. The stool characteristic of yellow-brown coloration indicates excretion of bilirubin.
The newborn at 24 hours of age has a red blood cell (RBC) count of 5.4 million per milliliter. Which entry should the nurse expect to find in the newborn's chart to explain this laboratory value? 1. Cord clamping delayed until pulsation ceased. 2. Infant is breastfed 15 to 20 minutes every 3 hours. 3. CBC drawn from the anterior surface of the left hand. 4. Placental abruption noted to be 80% at time of delivery
Answer: 1 Explanation: 1. Delayed cord clamping can cause an increase of up to 61%, resulting in a slightly higherthan-average RBC count. 2. Breastfeeding does not impact RBC counts in the first day of life. 3. Venous blood has lower RBC counts than do capillary blood samples. 4. Maternal or fetal blood loss causes hypovolemia and low RBC counts (less than 5.2 million per milliliter).
The nurse manager of the neonatal intensive care unit is preparing a handout for new parents. Which statement should the nurse include? 1. Neonates have a tendency to become dehydrated. 2. Sugar is always present in the urine of a newborn. 3. The kidneys are fully functional by 30 weeks' gestation. 4. Newborns can eliminate excess fluid as quickly as an adult.
Answer: 1 Explanation: 1. Neonates cannot concentrate their urine or pull water back into the vascular volume, and thus can become dehydrated easily. 2. Glucose is not identified as always being present in the urine of a newborn. 3. Full nephron function does not develop until 34 to 36 weeks. 4. Newborns have difficulty eliminating excess fluid because of their relatively low glomerular filtration rate during the first 2 weeks of life.
The home care nurse notes jaundice on the skin over the sternum of a 3-day-old infant. What should the nurse explain to the parents about this finding? 1. "The liver of an infant is not fully mature and does not conjugate the bilirubin for excretion." 2. "The yellow color of your baby's skin indicates that you are breastfeeding too often." 3. "This is an abnormal finding related to your baby's bowels not excreting bilirubin as they should." 4. "The infant received too many red blood cells after delivery because the cord was not clamped immediately."
Answer: 1 Explanation: 1. Physiologic jaundice is a common occurrence and peaks on day 3 or 4. 2. Frequent feeding will decrease jaundice. 3. Bilirubin binds to the proteins in breast milk and formula for excretion through the bowels 4. It happens in part because of the red blood cell destruction that infants experience combined with liver immaturity, which leads to less efficient conjugation of bilirubin for excretion.
The nurse is instructing the parents of a newborn about the number of wet diapers to expect each day. Which statement by the parents indicates that further education is necessary? 1. "Our baby was born with kidneys that are too small." 2. "Feeding our baby frequently will help the kidneys function." 3. "Kidney function in an infant is very different from in an adult." 4. "A baby's kidneys do not concentrate urine well for several months.
Answer: 1 Explanation: 1. Size of the kidneys is rarely an issue. 2. Frequent feeding helps maintain the fluid volume. 3. The ability to concentrate urine develops by 3 months of age. The inability to concentrate urine due to limited tubular reabsorption and lower glomerular filtration rate are the main differences between kidney function in a newborn and normal adult kidney function. 4. Counting wet diapers indicates urine output in relation to fluid intake.
The nurse is teaching new parents how to dress their newborn. Which statements indicate that teaching has been effective? Select all that apply. 1. "Our baby will have a much faster rate of breathing if he is not dressed warmly enough." 2. "When we change the baby's diaper, we should change any wet clothing or blankets, too." 3. "It is important that we dry the baby off as soon as we give him a bath or shampoo his hair." 4. "We should make sure that we keep our home air conditioned so the baby does not overheat." 5. "If the baby's body temperature gets too low, he will warm himself up without any shivering."
Answer: 1, 2, 3, 5 Explanation: 1. A neonate with a low body temperature will increase oxygen consumption, which can lead to respiratory distress. 2. Changing wet clothing or blankets immediately prevents evaporation, one mechanism of heat loss. 3. Drying a wet baby prevents evaporation, one mechanism of heat loss. 4. Babies need to be kept warm. Cold ambient temperatures will increase the oxygen consumption of a newborn and can lead to respiratory distress. 5. Nonshivering thermogenesis is the mechanism used by newborns to warm themselves
The nurse is preparing teaching material for a new mother. What should the nurse include when instructing on areas to include when observing the infant? Select all that apply. 1. Touch 2. Vision 3. Hearing 4. Diaper care 5. General appearance
Answer: 1, 2, 3, 5 Explanation: When teaching on observing the baby, the nurse should include general appearance and the five senses - vision, hearing, touch, smell, and taste. Diaper care is included when teaching about the skin.
A new mother is planning to bottle feed her infant and wants helps with suppressing lactation. What should the nurse suggest to help this new mother? Select all that apply. 1. Wear a 24-hour support bra 2. Apply cabbage leaves to the breast tissue 3. Apply warm compresses every 4 to 6 hours 4. Massage lotion on the breasts 3 times a day 5. Avoid all nipple stimulation for 7 to 10 days
Answer: 1, 2, 5 Explanation: Nurses should advise the non-breastfeeding mother to avoid any stimulation of her breasts and nipples by her baby, herself, breast pumps, or her sexual partner until the sensation of fullness has passed (usually in 7 to 10 days). Such stimulation will increase milk production and delay the suppression process. Heat is avoided for the same reason. The wearing of a 24-hour support bra and the use of cabbage leaves and/or cold compresses should be helpful during this period of time
A postpartum patient who received epidural morphine prior to a cesarean birth is concerned about a severe headache that has persisted for several days. What should the nurse suggest to this patient? Select all that apply. 1. Ingest fluids with caffeine 2. Engage in moderate exercise 3. Increase the intake of all fluids 4. Lie in bed in a quiet dark room 5. Restrict the intake of warm fluids
Answer: 1, 3, 4 Explanation: For a spinal headache the nurse should instruct the patient to engage in bed rest in a quiet dark room. Caffeine and hydration are also helpful. Moderate exercise could exacerbate the headache. There is no reason to restrict the intake of warm fluids.
The nurse is monitoring a postpartum patient receiving methylergonovine maleate (Methergine). Which assessment findings should the nurse identify as being expected adverse effects of this medication? Select all that apply. 1. Nausea 2. Leg pain 3. Headache 4. Hypertension 5. Uterine cramping
Answer: 1, 3, 4, 5 Explanation: Common adverse effects of methylergonovine maleate (Methergine) include nausea, headache, hypertension, and uterine cramping. Leg pain is not an identified adverse effect of this medication.
The new father asks what his baby will experience while sleeping and awake. How should the nurse respond? 1. "Babies have several sleep and alert states. Keep watching and you will notice them." 2. "Newborns have two stages of sleep: deep or quiet sleep and rapid eye movement sleep." 3. "You may have noticed that your child was in an alert awake state for an hour after his birth." 4. "Birth is hard work for babies; it takes them a week or 2 to recover and become more awake."
Answer: 2 Explanation: 1. Although it is true that babies have several sleep and alert states, the wording of this response is condescending and not therapeutic. This is not the best response. 2. This statement is true. Teaching the parents how to detect the two sleep stages helps them tune in to their infant's behavioral states. 3. Although this statement is true, it does not respond to the father's question about sleeping now. 4. Recovery from the birth process only takes a day or 2. During that time, feedings should take place when the baby is in an alert state.
The nurse is planning an educational presentation on hyperbilirubinemia for nursery nurses. Which statement is most important to include in the presentation? 1. Antibiotics decrease the incidence of hyperbilirubinemia. 2. Total bilirubin is the sum of the direct and indirect levels. 3. Conjugated bilirubin is eliminated in the conjugated state. 4. Unconjugated bilirubin is neurotoxic and cannot cross the placenta.
Answer: 2 Explanation: 1. Because of the role of gut bacteria in converting conjugated bilirubin into urobilinogen, neonates who have been administered antibiotics have an increased incidence of hyperbilirubinemia. 2. This is true. Conjugated bilirubin is also referred to as direct, while unconjugated bilirubin is also referred to as indirect. 3. Conjugated bilirubin can be transformed back into unconjugated bilirubin prior to excretion by β-glucuronidase enzyme if gut bacteria have not transformed it into urobilinogen. 4. Unconjugated bilirubin is neurotoxic but crosses the placenta during fetal life for the maternal gastrointestinal system to conjugate and excrete.
A postpartum client calls the nursery to report that her 3-day-old newborn has passed a bright green stool. How should the nurse respond to the client? 1. "Your newborn has diarrhea." 2. "This is a normal occurrence." 3. "There may be a possible food allergy." 4. "Take your newborn to the pediatrician.
Answer: 2 Explanation: 1. The green color of stool is not characterized as diarrhea, but is a transitional stool that consists of part meconium and part fecal material. 2. By the third day of life, the newborn's stools appear brown to green in color. 3. The green color of stool is not due to food allergies. 4. It is not necessary for the client to take her newborn to the pediatrician
The nurse is teaching a group of new parents on ways to ensure body heat regulation of their newborns. Which diagram should the nurse use to explain the process of radiation Pictures (see pg 382-383 of Contemporary TB Question #20 Chapter 23)
Answer: 2 Explanation: 1. This diagram explains the process of convection. 2. This diagram explains the process of radiation. 3. This diagram explains the process of evaporation. 4. This diagram explains the process of conduction.
The mother of a 2-day-old infant newly diagnosed with sepsis asks why she could not detect the symptoms. What should the nurse reply to this mother? 1. "Your mothering skills will improve with time. You should take the newborn class." 2. "Newborns have immature immune function at birth, and illness is very hard to detect." 3. "Your baby did not get enough active acquired immunity from you during the pregnancy." 4. "The immunity your baby gets in utero does not start to function until 4 to 8 weeks of age."
Answer: 2 Explanation: 1. This response does not address the physiology of neonatal infection and is not therapeutic because it is blaming. 2. The immune system of a newborn lacks response to pyrogens and presents a limited inflammatory response; thus, the signs and symptoms of infection are often subtle and nonspecific in the newborn. 3. The mother develops active acquired immunity, which is passed to the newborn transplacentally as passive acquired immunity. This immunity is to the illnesses and infections she has had or been immunized against. 4. The passive acquired immunity a newborn receives from its mother is effective at birth and lasts from 4 weeks to 8 months, depending on the specific antibody
The nurse is preparing to administer a sitz bath to a postpartum patient. In which order should the nurse perform the steps of this procedure? 1. Open the clamp on the tubing 2. Anchor the infusion bag to the sitz bath basin, with the tube facing upward 3. Fill the drainage bag with warm or cool water up to the top line as indicated on the bag 4. Close the clamp on the tubing, dry perineum with a clean towel, and apply new peripad 5. Secure the drainage bag from a hook over the toilet or from the handle used to flush the toilet
Answer: 2, 3, 5, 1, 4 Explanation: When providing a sitz bath the nurse should: insert the large infusion bag or tube into the back of the sitz bath basin, anchoring it to the bottom of the basin with the small opening at the end of the tubing facing upward, toward the ceiling; fill the drainage bagwith warm or cool water up to the top line as indicated on the bag; secure the drainage bag from a hook over the toilet or from the handle used to flush the toilet if it is a few feet higher than the toilet; open the clamp on the tubing; once the sitz bath is complete, instruct the woman to close the clamp on the tubing, dry perineum with a clean towel, and apply new peri-pad.
The nurse is assessing a newborn at 1 hour of age. Which finding requires an immediate intervention? 1. Mean blood pressure 55 mmHg 2. Pulse rate 145, systolic murmur heard 3. Pauses in respiration lasting 30 seconds 4. Respiratory rate 60, crackles present bilaterally
Answer: 3 Explanation: 1. This is a normal finding in an infant at 1 hour of life. 2. This pulse rate is normal. Systolic murmurs are very unlikely to indicate serious pathology and are usually caused by incomplete closure of the ductus arteriosus or foramen ovale. 3. Pauses in respirations greater than 20 seconds are considered episodes of apnea and require further intervention. 4. This respiratory rate is normal; crackles are commonly heard in the first few hours after birth as the infant reabsorbs the fluid in the lungs that was present at birth.
A new grandfather is marveling over his 12-hour-old newborn grandson. Which statement indicates that the grandfather needs additional education? 1. "I cannot believe he can already digest fats, carbohydrates, and proteins." 2. "It is amazing that his whole digestive tract moves things along at birth." 3. "Incredibly, his stomach capacity is already a cupful when he was born." 4. "He will lose some weight but then miraculously regain it by about 10 days."
Answer: 3 Explanation: 1. At birth, neonates can digest fats, simple carbohydrates, and proteins. 2. Gastric emptying and intestinal peristalsis occur during in utero life; the first bowel movement usually occurs in the first day of life. 3. A newborn's stomach capacity is only 50 to 60 mL; overfeeding of bottle-fed infants tends to cause regurgitation and abdominal discomfort, exhibited by crying. 4. Neonates lose 5% to 10 % of their birth weight in the first days after life, especially if they are breastfed. They should have regained the lost weight and should be back to their birth weight by 10 days of age.
The nurse notes that a 1-day-old infant's immunoglobulin M (IgM) antibodies are elevated. Which is the least likely cause for this elevation? 1. Placental leakage 2. Intrauterine exposure to syphilis 3. Intrauterine exposure to TORCH (toxoplasmosis, rubella, cytomegalovirus, herpesvirus hominis type 2 infection) syndrome 4. Maternal-fetal transfer of IgM while in utero
Answer: 4 Explanation: 1. Elevated levels of IgM at birth may indicate placental leaks. 2. Elevations in IgM may be due to newborn exposure to an intrauterine infection such as syphilis. 3. Elevations in IgM at birth may be due to newborn exposure to an intrauterine infection such as TORCH syndrome. 4. Because IgM does not normally cross the placenta, most or all of it is produced by the fetus beginning at 10 to 15 weeks' gestation.
Nursing students describe actions while practicing physical assessment of a newborn using a model. Which nursing student's statement indicates the need for further teaching? 1. "I auscultated the infant's heart tones for 1 minute." 2. "I palpated peripheral pulses in all the newborn's extremities." 3. "I obtained a higher blood pressure on the legs than on the arms." 4. "I obtained the infant's heart rate by observing the cardiac monitor.
Answer: 4 Explanation: 1. Apical pulse rates should be obtained by auscultation for a full minute, preferably when the newborn is asleep. 2. Peripheral pulses of all extremities should also be evaluated to detect any inequalities or unusual characteristics. 3. Blood pressure in the lower extremities is usually higher than that in the upper extremities. 4. Physical assessment of the newborn's heart rate requires auscultation of the apical pulse for a full minute.
The nurse is planning the care of a 1-day-old infant. Which intervention would protect the newborn from heat loss by convection? 1. Drying the newborn thoroughly 2. Prewarming the examination table 3. Removing wet linens from the isolette 4. Placing the newborn away from air currents
Answer: 4 Explanation: 1. Drying the newborn thoroughly immediately after birth or after a bath will prevent heat loss by evaporation. 2. Prewarming the examination table reduces heat loss by conduction. 3. Removing wet linens that are not in direct contact with the newborn from the isolette reduces heat loss by radiation. 4. Placing the newborn away from air currents reduces heat loss by convection.
The nurse is reviewing the medical records of several newborns. Which infant requires immediate intervention? 1. 24-hour-old term male with total bilirubin level of 2 2. 3-day-old term bottle-fed female with bilirubin of 11 3. 2-week-old postterm breastfed male with bilirubin of 10 4. 12-hour-old preterm female exhibiting icterus and lethargy
Answer: 4 Explanation: 1. Total bilirubin levels under 3 are expected in the first 24 hours of life. 2. Physiologic jaundice peaks between days 3 and 5; a total bilirubin level of 11 is not treated with phototherapy, regardless of feeding method. 3. Breast milk jaundice peaks at 2 to 3 weeks of age and commonly presents with a total bilirubin level of 5 to 10. 4. Jaundice is an indication of hyperbilirubinemia and is not an expected finding in the first day of life. Lethargy can be a sign of kernicterus developing. Preterm infants are more likely to develop jaundice
A newborn weighing 7.7 lb has an estimated bladder capacity of 20 mL. If 25 mL/kg of urine is expected to be produced each day, how many diaper changes will this baby need? (Calculate by rounding to the nearest whole number.)
Answer: 4 Explanation: First determine the baby's weight in kilograms by dividing 7.7 pounds by 2.2, or 7.7/2.2 = 3.5 kg. Then multiply the weight by 25 mL/kg = 25 × 3.5 = 87.5, which is the amount of urine produced by the newborn. Then divide the total amount of urine by the bladder capacity of 20 mL, or 87.5/20 = 4.375. With rounding, the baby will need an estimated 4 diaper changes each day
A newborn weighing 8.8 lb is prescribed bottle-feedings every 3 hours to achieve the caloric intake of 120 calories/kg each day. How many calories should be in each ounce of feeding? (Calculate to the nearest whole number.)
Answer: 60 calories Explanation: First determine the infant's weight in kilograms by dividing the weight in pounds by 2.2, or 8.8/2.2 = 4 kg. Then determine the total number of calories per day by multiplying 120 calories × 4 = 480. Then divide the total calories by 8 (feedings every 3 hours are determined by dividing 24 hours by 3 = 8), or 480/8 = 60 calories. Each feeding should provide the newborn with 60 calories
The nurse is performing discharge teaching for a newly delivered first-time mother and her infant on the 2nd postpartum day. Which statement by the mother indicates that teaching has been successful? A) "Taking baths will help my perineum feel less sore each day." B) "If I develop heavy bleeding, I should take my temperature." C) "My bowel movements should resume in a week." D) "I will go back to the doctor in 4 days for my RhoGAM shot."
Answer: A Explanation: A) A sitz bath or tub bath promotes healing and provides relief from perineal discomfort during the initial weeks following birth. B) If heavy bleeding begins, the client should call her healthcare provider immediately, not take her temperature. Postpartum hemorrhage can be lifethreatening. C) Bowel movements should resume in 2 to 3 days after birth. A week is too long a time frame, and indicates constipation. D) When RhoGAM is needed, it is given within 72 hours of birth, while still at the hospital.
A variety of drugs are used either alone or in combination to provide relief of postpartum pain. Which of the following would be an option for pain relief? A) Nonsteroidal anti-inflammatory agents B) Proquad C) Methergine D) Intravenous oxytocin
Answer: A Explanation: A) A variety of drugs are used alone or in combination to provide relief of postpartum pain. An option would include nonsteroidal anti-inflammatory agents such as ibuprofen and ketorolac. B) Proquad is a measles, mumps, rubella, and varicella live virus vaccine. C) Methergine is prescribed to promote uterine contractions. D) Intravenous oxytocin (Pitocin) remains the first-line drug for excessive bleeding related to postpartum uterine atony.
The nurse is assessing clients after delivery. For which client is early discharge at 24hours after delivery appropriate? A) Woman and baby who have had two successful breast feedings B) Woman who is bottle-feeding her infant and has not voided since delivery C) Twins delivered at 35 weeks, bottle-feeding D) Cesarean birth performed for fetal distress
Answer: A Explanation: A) Early discharge may be advantageous if mother and baby are doing well, help is available for the mother at home, and the family and physician/C NM agree that both clients are healthy and ready for discharge. Feeding successfully is one of the physiologic needs of the infant and both mother and infant appear to be doing well. B) Early discharge may be advantageous if mother and baby are doing well. Voiding is a physiologic need of the mother and has not yet been accomplished. C) Preterm infants are not appropriate for early discharge. D) Infants who experienced distress in labor are not appropriate for early discharge
A client who delivered 2 hours ago tells the nurse that she is exhausted and feels guilty because her friends told her how euphoric they felt after giving birth. How should the nurse respond? A) "Everyone is different, and both responses are normal." B) "Most mothers do feel euphoria; I don't know why you don't." C) "It's good for me to know that because it might indicate a problem." D) "Let me bring your baby to the nursery so that you can rest."
Answer: A Explanation: A) Following birth, some women feel exhausted and in need of rest. Other women are euphoric and full of psychic energy, ready to retell their experience of birth repeatedly. B) The nurse should not imply that a mother's emotional response is not expected. C) Both euphoria and exhaustion are normal feelings after birth. Fatigue after birth is not indicative of a problem. D) The client might want to be with her newborn, and the nurse should not encourage unnecessary separation of mother and child.
The nurse assesses the postpartum client to have moderate lochia rubra with clots. Which nursing intervention would be appropriate? A) Assess fundus and bladder status. B) Catheterize the client. C) Administer Methergine IM per order. D) Contact the physician immediately
Answer: A Explanation: A) The amount, consistency, color, and odor of the lochia are monitored on an ongoing basis. Increased bleeding is most often related to uterine atony and responds to fundal massage, expression of any clots, and emptying the bladder. B) Catheterizing the client might be an intervention if the bladder is full and the clientis unable to void, but it is not the initial intervention. C) It is not necessary to administer Methergine IM per order; the situation does notwarrant this intervention. D) It is not necessary to contact the physician immediately; the situation does notwarrant this intervention.
The nurse is planning care for three newly delivered adolescents and their babies. What should the nurse keep in mind when planning their care? A) The baby's father should be encouraged to participate when the nurse is providing instruction. B) A class for all the adolescents would decrease teaching effectiveness. C) The schools that the adolescents attend will provide teaching on bathing. D) Adolescents understand the danger signals in newborns.
Answer: A Explanation: A) The father, if he is involved, should be included as much as possible. If classes are offered in the hospital during the postpartum stay, the adolescent mother and father should be strongly encouraged to attend and participate. B) If classes are offered in the hospital during the postpartum stay, the adolescent mother and father should be strongly encouraged to attend and participate. C) The nurse should never assume that basic newborn care education will be provided to a client elsewhere. D) Group classes for adolescent mothers should include infant care skills, information about growth and development, infant feeding, well-baby care, and danger signals in the ill newborn
The nurse is preparing to administer postpartum neuraxial morphine to a client who is morbidly obese. For which side effect related to morbid obesity should the nurse monitor? A) Respiratory depression B) Confusion C) Constipation D) Hypotension
Answer: A Explanation: A) Women who are morbidly obese are at increased risk for respiratory depression, which is managed by administration of naloxone (Narcan), mask ventilation, and endotracheal intubation with mechanical ventilation, if necessary. B) The client is not at increased risk of confusion, as this is not affected by postpartum neuraxial morphine administration in the context of morbid obesity. C) The client is not at increased risk of constipation, as this is not affected by postpartum neuraxial morphine administration in the context of morbid obesity. D) The client is not at increased risk of hypotension, as this is not affected by postpartum neuraxial morphine administration in the context of morbid obesity.
The incidence of complications and discomforts in the first year postpartum is common and women may experience which of the following? Select all that apply. A) Pain B) Excess energy C) Urinary incontinence D) Changes in mental health status E) Sleep deprivation
Answer: A, C, D, E Explanation: A) Pain can be a discomfort in the first year postpartum. B) Fatigue, not excess energy, can be a discomfort in the first year postpartum. C) Urinary incontinence can be a complication in the first year postpartum. D) Changes in mental health status can be a complication in the first year postpartum. E) Sleep deprivation can be a complication in the first year postpartum
The nurse is caring for a client who had a cesarean birth 4 hours ago. Which interventions would the nurse implement at this time? (Select all that apply) A) Administer analgesics as needed. B) Encourage the client to ambulate to the bathroom to void. C) Encourage leg exercises every 2 hours. D) Encourage the client to cough and deep-breathe every 2 to 4 hours. E) Encourage the use of breathing, relaxation, and distraction.
Answer: A, C, D, E Explanation: A) The nurse continues to assess the woman's pain level and provide relief measures as needed. B) Ambulation should begin no later than 24 hours postoperatively and should be encouraged at least 2 to 3 times a day, but not in the first 4 hours. C) Within the first 12 hours postoperatively, unless medically contraindicated, the woman should be assisted to dangle her legs off the side of the bed. D) The woman is encouraged to cough and breathe deeply and to use incentive spirometry every 2 to 4 hours while awake for the first few days following cesarean birth. E) The nurse should encourage the use of breathing, relaxation, and distraction techniques
A new grandmother comments that when her children were born, they stayed in the nursery. The grandmother asks the nurse why her daughter's baby stays mostly in the room instead of the nursery. How should the nurse respond? A) "Babies like to be with their mothers more than they like to be in the nursery." B) "Contact between parents and babies increases attachment." C) "Budget cuts have decreased the number of nurses in the nursery." D) "Why do you ask? Do you have concerns about your daughter's parenting?"
Answer: B Explanation: A) Although most newborns cry less when held than when in their cribs, this is not the most important reason for encouraging mothers to spend time with their babies. B) In a mother-baby unit, the newborn's crib is placed near the mother's bed, where she can see her baby easily; this is conducive to an on-demand feeding schedule for both breastfeeding and formula-feeding infants. C) Budget cuts are not a reason for babies' being in the nursery less than in the past. D) It is not therapeutic to use the word "why." The grandmother has not indicated that she has any concerns about her daughter's parenting
A multiparous client delivered her first child vaginally 2 years ago, and delivered an infant by cesarean yesterday due to breech presentation. Which statement would the nurse expect the client to make? A) "I can't believe how much more tired I was with the first baby." B) "I'm having significantly more pain this time than with my last birth." C) "It is disappointing that I can't breastfeed because of the cesarean." D) "Getting in and out of bed feels more comfortable than last time."
Answer: B Explanation: A) Mothers who have experienced cesareans, particularly unanticipated ones that follow lengthy labors, may be fatigued, sleep deprived, and under the influence of medications that alter their level of consciousness. B) Women with cesarean births have special needs: increased need for rest and sleep; incisional care; self-care; and relief of pain and discomfort. C) Breastfeeding is not contraindicated by cesarean birth. D) Getting in and out of bed is more painful after cesarean birth than after vaginal birth. The nurse can assist the woman in identifying interventions to relieve discomfort or pain. The woman should be encouraged to take pain medication regularly, engage in frequent rest periods, avoid prolonged activity, and observe for signs of "overdoing it."
The postpartum client expresses concern about getting back to her prepregnant shape, and asks the nurse when she will be able to run again. Which statement by the client indicates that teaching was effective? A) "I can start running in 2 weeks, and can breastfeed as soon as I am done." B) "I should see how my energy level is at home, and increase my activity slowly." C) "Running is not recommended for breastfeeding women." D) "If I am getting 8 hours of sleep per day, I can start running."
Answer: B Explanation: A) Running should not be initiated until after 6 weeks postpartum or with medical approval. The nurse can provide the new mother with suggestions for resuming her normal level of activity. Breastfeeding should take place prior to running to minimize chest discomfort. B) Women should be encouraged to limit the number of activities to prevent excessive fatigue, increase in lochia, and negative psychologic reactions, such as feeling overwhelmed. A regular exercise program including vigorous activities such as running, weight lifting, or competitive sports can usually be initiated after the 6-week postpartum examination or when approved by the client's physician/CNM. C) This statement is not true. It is more comfortable to nurse prior to running, but running is not contraindicated and can usually be initiated after the 6-week postpartum examination or when approved by the client's physician/CNM. D) This response does not address a more important factor, which is encouraging the client to assess her own energy level and to gradually return to previous activity levels.
A postpartum client has just received a rubella vaccination. The client demonstrates understanding of the teaching associated with administration of this vaccine when she states which of the following? A) "I will need another vaccination in 3 months." B) "I must avoid getting pregnant for 1 month." C) "This will prevent me from getting chickenpox." D) "This will protect my newborn from getting the measles."
Answer: B Explanation: A) The client will not need another vaccination in 3 months. B) The client must avoid pregnancy for at least 1 month after receiving the rubella vaccine. C) The vaccination prevents measles, not chickenpox. D) The vaccination will only protect the client receiving it; therefore, the newborn will not be protected until the child receives his own vaccination
Which statement by a nursing student preparing to care for a postpartum lesbian mother would indicate that the student is prepared for the teaching? A) "I can't let the client know I've never worked with lesbian mothers." B) "I will have to adjust some of my discharge instruction for this mother." C) "I don't need to include the partner when I provide care and instruction." D) "Discharge teaching is exactly the same for lesbian mothers as for all others.
Answer: B Explanation: A) The nurse should ask the patient for guidance regarding any special needs or requests that she or her partner may have. B) The nurse should be aware that standardized postpartum instructions, particularly those related to intercourse and contraception, might need to be individualized and amended. C) Providing quality patient-centered care for any postpartum woman involves acknowledging, welcoming, and involving her intimate partner in care and decision making. D) The nurse should be aware that standardized postpartum instructions, particularly those related to intercourse and contraception, might need to be individualized and amended
The client having her second child is scheduled for a cesarean birth because the baby is in a breech presentation. The client states, "I'm wondering what will be different this time compared with my first birth, which was vaginal." What response is best? A) "We'll take good care of you and your baby. You'll be home before you know it." B) "You'll be wearing a sequential compression device until you start walking." C) "You will have a lot of pain, but there are medications that we give when it gets really bad." D) "You won't be able to nurse until the baby is 12 hours old, because of your epidural."
Answer: B Explanation: A) This response focuses on the nurse, and does not provide specific information to answer the client's question. B) The use of sequential compression devices (SCDs) and early ambulation are essential to the prevention of deep vein thrombosis, especially if the client had a cesarean birth. C) Focusing on the pain is a negative emphasis and pain can also be a factor in a vaginal birth. D) Epidural anesthesia prevents leg function, and therefore ambulation, but does not impact a mother's ability to breastfeed.
The nurse is caring for a client who delivered by cesarean birth. The client received a general anesthetic. To prevent or minimize abdominal distention, which of the following would the nurse encourage? Select all that apply A) Increased intake of cold beverages B) Leg exercises every 2 hours C) Abdominal tightening D) Ambulation E) Using a straw when drinking fluids
Answer: B, C, D Explanation: A) The woman should avoid carbonated or very hot or cold beverages, as they would increase the distention through the increase of gas and constipation. B) Immobility increases the risk of abdominal distention and discomfort. Leg exercises serve to prevent or minimize abdominal distention in a surgical client who received a general anesthetic. C) Abdominal tightening serves to prevent or minimize abdominal distention in a surgical client who received a general anesthetic. D) Early ambulation prevents abdominal distention that can occur with excess accumulation of gas in the intestines. E) The woman should avoid the use of straws to avoid increasing the distention through increase of gas and constipation
The nurse is caring for a client who plans to relinquish her baby for adoption. The nurse would implement which approach to care? Select all that apply A) Encourage the client to see and hold her infant. B) Encourage the client to express her emotions. C) Respect any special requests for the birth. D) Acknowledge the grieving process in the client. E) Allow access to the infant, if the client requests it.
Answer: B, C, D, E Explanation: A) Encouraging the client to see and hold her infant does not respect the client's right to refuse interaction. The amount of contact she chooses to have with her newborn should be respected. B) The mother who decides to relinquish her baby needs emotional support and validation of her loss. C) The woman should decide whether to see and hold her baby and should have any special requests regarding the birth honored. D) Perinatal nurses should be aware that relinquishing mothers are at risk for disenfranchised grief, in which they are unable to proceed through the grieving process and come to resolution with the loss. The nurse should acknowledge the woman's loss and support her decision. E) The amount of contact she chooses to have with her newborn should be respected.
On the 3rd day postpartum, a client who is not breastfeeding experiences engorgement. To relieve her discomfort, the nurse should encourage the client to do which of the following? A) Remove her bra B) Apply heat to the breasts C) Apply cold packs to the breasts D) Use a breast pump to release the milk
Answer: C Explanation: A) A support bra is recommended. B) Applying heat would stimulate milk production. C) Applying cold packs to the breasts relieves discomfort and helps suppress lactation. D) Using a breast pump would stimulate milk production and delay the suppression process.
The nurse is caring for a 15-year-old client who gave birth to her first child yesterday. What action is the best indicator that the nurse understands the parenting adolescent? A) The client's mother is included in all discussions and demonstrations. B) The father of the baby is encouraged to change a diaper and give a bottle. C) The nurse explains the characteristics and cues of the baby when assessing him. D) A discussion on contraceptive methods is the first topic of teaching.
Answer: C Explanation: A) Although the grandmother or another family member may plan to assist with or provide much of the newborn care in some cases, the nurse should always ensure that the adolescent mother has the knowledge and demonstrates the skills to provide care for her newborn before discharge. B) The father, if he is involved, should be included as much as possible, but having the mother learn more about her new baby is a higher priority. C) A newborn physical examination performed at the bedside gives the parent(s) immediate feedback about the newborn's health and demonstrates methods of handling an infant. This action helps the client learn about her baby as an individual and facilitates maternal-infant attachment. This is the highest priority. D) The nurse should offer detailed teaching on contraception, as the young woman may have no prior experience with it and may not feel comfortable requesting this information, but establishing rapport and facilitating understanding of and attachment to the newborn is a higher priority
The nurse is preparing a teaching brochure for Spanish-speaking postpartum clients. Which topics are critical for this population? A) Baby baths and birth certificates B) Hygiene practices C) When and how to contact their healthcare provider D) Pain-relief options in labor and after birth
Answer: C Explanation: A) Baby baths and birth certificates are necessary information, but not critical. B) It is important to consider cultural practices and realize that some women may prefer not to shower in the first few days following birth. Some Hispanic women prefer to delay showering. Hygiene practices are important, but not critical. C) Knowing how to contact their healthcare provider at all times is critical so that clients receive appropriate advice and care in case of a problem or emergency. Knowing what to watch for and when to call the healthcare provider also facilitates safety. These are the highest priorities. D) Pain relief is important, but not critical.
The nurse is supervising a student nurse who is working with a 14-year-old client who delivered her first child yesterday. Which statement indicates that the nursing student understands the particular needs of an adolescent client? A) "This client will need less teaching, because she will have gotten the right information in school." B) "Because of her age, this client will require less frequent fundal checks to assess for post partal hemorrhage." C) "Because of her age, this client will probably need extra teaching about the terminology for her anatomy." D) "This client will need to have her grandmother provide day care and help raise the baby."
Answer: C Explanation: A) Public or private education likely does not cover the extent of the information that the adolescent needs to know about pregnancy and delivery. The nurse has many opportunities for teaching adolescent parents about their newborn in the postpartum unit and serves as a role model for new parents when responding to and caring for the newborn. B) Adolescent mothers have the same basic physical care needs as older mothers. C) Some adolescents may not have a working knowledge of their own anatomy and physiology or the related terminology, and they may require special assistance with postpartum hygiene and care. D) Although the client will require day care to continue with her education, the assistance does not have to come from her grandmother
)The breastfeeding client asks the nurse about appropriate contraception. What is the nurse's best response? A) "Breastfeeding has many effects on sexual intercourse." B) "IUDs are easy to use and easy to insert prior to sexual intercourse." C) "It's possible to get pregnant before your menstrual period returns. Let's talk about some different options for contraception." D) "Breastfeeding hampers ovulation, so no contraception is needed."
Answer: C Explanation: A) This answer does not address the client's question about contraception. B) IUDs can only be placed by a healthcare provider in a clinic situation. C) The nurse should discuss the importance of contraception during the early postpartum period and provide information on the advantages and disadvantages of different methods, including special considerations for breastfeeding mothers. The woman's body needs adequate time to heal and recover from the stress of pregnancy and childbirth. D) Breastfeeding hampers ovulation, but to be safe, breastfeeding women should use a contraceptive. The nurse should discuss the importance of contraception during the early postpartum period and provide information on the advantages and disadvantages of different methods, including special considerations for breastfeeding mothers.
The nurse is providing education to the new family. Which question by the nurse is best? A) "Do you know how to give the baby a bath?" B) "You have diapers and supplies at home, right?" C) "How have your breast feedings been going?" D) "How much formal education do you have?"
Answer: C Explanation: A) This is a closed question; closed questions should be avoided. Also, bathing is a lowerpriority need than is feeding. B) This is a leading question. Leading questions should be avoided. C) This is an open-ended question about an important physiologic issue. A discussion that includes both partners can facilitate an open dialog between themand can provide an opportunity for questions and answers. D) Although the family members' level of educational attainment helps when choosing written materials and words, it is rude to ask outright what education they have had.
What is the advantage of a client using a patient-controlled analgesia (PCA) following a cesarean birth? A) The client receives a bolus of the analgesia when pressing the button. B) The client experiences pain relief within 30 minutes. C) The client feels a greater sense of control, and is less dependent on the nursing staff. D) The client can deliver as many doses of the medication as needed.
Answer: C Explanation: A) With this approach, the woman is given a bolus of analgesia, often morphine, at the beginning of therapy and is not repeated. B) IV pain medications provide rapid pain relief. C) Using a special intravenous (IV) pump system, the woman presses a button to selfadminister small doses of the medication as needed. For safety, the pump is preset with a time lockout so that the pump cannot deliver another dose until a specified time has elapsed. Women using PCA feel less anxious and have a greater sense of control with less dependence on the nursing staff. D) For safety, the pump is preset with a time lockout so that the pump cannot deliver another dose until a specified time has elapsed
The nurse is planning discharge teaching for a postpartum woman. What recommendations should the woman receive before being discharged? Select all that apply. A) To abstain from sexual intercourse for 6 months B) To avoid showers for 4 weeks C) To avoid overexertion D) To practice postpartum exercises E) To obtain adequate rest
Answer: C, D, E Explanation: A) The client should abstain from sexual intercourse until lochia has ceased. B) The client may take a shower and may continue sitz baths at home if she desires. C) The client should avoid overexertion. D) The client should receive information and instruction on postpartum exercises. E) The client should receive information on the need for adequate rest.
The nurse is preparing to receive a newly delivered client. The client is a young single mother who is relinquishing custody of her newborn through an open adoption. What action is most important? A) Assign the client a room on the GYN surgical floor instead of on the postpartum floor. B) Prepare to complete teaching in time for discharge at 24 hours post-delivery. C) Make an effort not to bring up the topic of the baby, and discuss the mother's health instead. D) Ask the client how much contact she would like with the baby, and whether she wants to feed it.
Answer: D Explanation: A) Clients relinquishing their newborns should be given options concerning contact with the infant, including where they would feel most comfortable if they opt for contact at all. B) Not all clients who relinquish their infants want early discharge. C) It is up to the client to decide how much she wants to talk about her birth, her newborn, or her decision to relinquish the child. D) Assessing the birth mother's preferences by respectfully asking questions and making no assumptions facilitates a more positive experience.
To actively involve the post partal client during discharge teaching, the postpartum nurse applies which learning principle? A) Reprints of magazine articles B) Classroom lectures C) Audiotapes D) Interactive nurse-patient relationships
Answer: D Explanation: A) Providing magazine articles does not actively involve the client in learning. B) Classroom lectures do not actively involve the client in learning. C) Listening to audiotapes does not actively involve the client in learning. D) Effective parent learning requires precise timing of teaching, as well as choice of a teaching method that is effective for the family, such as DVDs and return demonstration. Content on self-care, infant care, and anticipatory guidance is important.
The hospital is developing a new maternity unit. What aspects should be included in the planning of the new unit to best promote family wellness? A) Normal newborn nursery centrally located to all client rooms B) A kitchen with a refrigerator stocked with juice and sandwiches C) Small, cozy rooms with a client bed and rocking chair D) A nursing care model based on providing couplet care
Answer: D Explanation: A) Rooming-in provides the childbearing family with opportunities to interact with their newborn during the first hours and days of life. B) Although having snacks can be good for postpartum clients, some cultures prohibit drinking cold liquids after birth. C) Small rooms can become overly crowded when siblings and grandparents come to visit. Larger rooms that facilitate family attachment are better. D) Couplet care, which is care of both the mother and her baby, is an important part of the family-centered care approach, in which the infant remains at the mother's bedside and both are cared for by the same nurse.
A woman gave birth 48 hours ago to a healthy infant girl. She has decided to bottle feed. During the assessment, the nurse notices that both breasts are swollen, warm, and tender on palpation. Which guidance should the nurse provide to the client at this time? A. Run warm water on her breasts during a shower B. Apply ice to the breasts for comfort C. Express small amounts of milk from the breasts to relieve the pressure D. Wearing a loose-fitting bra to prevent nipple irritation
B. Apply ice to the breasts for comfort
When caring for a newly delivered woman, what is the best measure to prevent abdominal distention after a cesarean birth? A. Rectal suppositories B. Early and frequent ambulation C. Tightening and relaxing abdominal muscles D. Carbonated beverages
B. Early and frequent ambulation
Postpartum fatigue (PPF) is more than just feeling tired. It is a complex phenomenon affected by physiologic, psychologic, and situational variables. Which factors contribute to this phenomenon? (Select all that apply.) A. Precipitous labor B. Hospital routines C. Bottle feeding D. Anemia E. Excitement
B. Hospital routines D. Anemia E. Excitement
What information should the nurse understand fully regarding rubella and Rh status? A. Breastfeeding mothers cannot be vaccinated with the live attenuated rubella virus B. Women should be warned that the rubella vaccination is teratogenic and that they must avoid pregnancy for at least 1 month after vaccination C. Rh immunoglobulin is safely administered intravenously because it cannot harm a nursing infant D. Rh immunoglobulin boosts the immune system and thereby enhances the effectiveness of vaccinations
B. Women should be warned that the rubella vaccination is teratogenic and that they must avoid pregnancy for at least 1 month after vaccination
Under the Newborns' and Mothers' Health Protection Act, all health plans are required to allow new mothers and newborns to remain in the hospital for a minimum of _____ hours after a normal vaginal birth and for _____ hours after a cesarean birth. What is the correct interpretation of this legislation? A. 24; 72 B. 24; 96 C. 48; 96 D. 48; 120
C. 48; 96
Postpartum overdistention of the bladder and urinary retention can lead to which complications? A. Postpartum hemorrhage and eclampsia B. Fever and increased blood pressure C. Postpartum hemorrhage and urinary tract infection D. Urinary tract infection and uterine rupture
C. Postpartum hemorrhage and urinary tract infection
A recently delivered mother and her baby are at the clinic for a 6-week postpartum checkup. Which response by the client alerts the nurse that psychosocial outcomes have not been met? A. The woman excessively discusses her labor and birth experience B. The woman feels that her baby is more attractive and clever than any others C. The woman has not given the baby a name D. The woman has a partner or family members who react very positively about the baby
C. The woman has not given the baby a name
Contemporary****
Contemporary****
Parents who have not already done so need to make time for newborn follow-up of the discharge. According to the American Academy of Pediatrics (AAP), when should a breastfeeding infant first need to be seen for a follow-up examination? A. 2 weeks of age B. 7 to 10 days after childbirth C. 4 to 5 days after hospital discharge D. 48 to 72 hours after hospital discharge
D. 48 to 72 hours after hospital discharge
Which nursing action is most appropriate to correct a boggy uterus that is displaced above and to the right of the umbilicus? A. Notify the physician of an impending hemorrhage B. Assess the blood pressure and pulse C. Evaluate the lochia D. Assist the client in emptying her bladder
D. Assist the client in emptying her bladder
A 25-year-old multiparous woman gave birth to an infant boy 1 day ago. Today her husband brings a large container of brown seaweed soup to the hospital. When the nurse enters the room, the husband asks for help with warming the soup so that his wife can eat it. What is the nurses most appropriate response? A. Didn't you like your lunch B. Does your physician know that you are planning to eat that? C. What is that anyway? D. Ill warm the soup in the microwave for you
D. Ill warm the soup in the microwave for you
Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the woman empty her bladder spontaneously as soon as possible. If all else fails, what tactic might the nurse use? A. Pouring water from a squeeze bottle over the woman's perineum. B. Placing oil of peppermint in a bedpan under the woman. C. Asking the physician to prescribe analgesic agents D. Inserting a sterile catheter.
D. Inserting a sterile catheter.
The trend in the United States is for women to remain hospitalized no longer than 1 or 2 days after giving birth. Which scenario is not a contributor to this model of care? A. Wellness orientation model of care rather than a sick-care model B. Desire to reduce health care costs C. Consumer demand for fewer medical interventions and more family-focused experiences D. Less need for nursing time as a result of more medical and technologic advances and devices available at home that can provide information
D. Less need for nursing time as a result of more medical and technologic advances and devices available at home that can provide information
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. What is the nurses highest priority at this time? A. Beginning an intravenous (IV) infusion of Ringers lactate solution B. Assessing the womans vital signs C. Calling the womans primary health care provider D. Massaging the womans fundus
D. Massaging the womans fundus
A woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of sitz bath three times daily, and a stool softener. Which information regarding the clients condition is most closely correlated with these orders? A. Woman is a gravida 2, para 2 B. Woman had a vacuum-assisted birth C. Woman received epidural anesthesia D. Woman has an episiotomy
D. Woman has an episiotomy
McKinney*****
McKinney*****
Olds*****
Olds*****