Families Module 2 Exam

The uterine fundus 1 hour after delivery is palpable at A. Level of xiphoid process B. Level of umbilicus C. Level of symphysis pubis D. Midway between umbilicus and symphysis pubis

B. Level of umbilicus

The nurse manager is presenting education to her staff to promote consistency in the interventions used with lactating mothers. She emphasizes that the optimum time to initiate lactation is: A. as soon as possible after the infant's birth. B. after the mother has rested for 4-6 hours. C. during the infant's second period of reactivity D. after the infant has taken sterile water without complications

A. as soon as possible after the infant's birth.

The minimum birth weight for full term babies to be considered normal is: A. 2,000 grams B. 1,500 grams C. 2,500 grams D. 3,000 grams

C. 2,500 grams The reference range for birth weight is 2,500 to 4,000 grams (5.5 to 8.8 pounds)

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

A. Having the children choose or make a gift to give to the new baby upon its arrival home Special time should be set aside just for the other children without interruption from the newborn. Someone other than the mother should carry the baby into the home so she can give full attention to greeting her other children. Children should be actively involved in the care of the baby according to their ability without overwhelming them.

Which behaviors would be exhibited during the letting-go phase of maternal role adaptation. Select all that apply. A. Emergence of family unit B. Dependent behaviors C. Sexual intimacy relationship continuing D. Defining one's individual roles E. Being talkative and excited about becoming a mother

A, C, D Emergence of family unit, sexual intimacy relationship continuing, and defining one's individual roles represent interdependent behaviors associated with the letting-go phase. Dependent behaviors are exhibited in the taking-in phase. Being talkative and excited about becoming a mother represents the taking-hold phase and is an example of dependent-independent behaviors.

During the postpartum period, the fundus of the uterus is expected to go down normally about __ cm per day. A. 1 cm B. 2 cm C. 2.5 cm D. 3 cm

A. 1 cm The uterus will begin involution right after delivery. It is expected to regress/go down by 1 cm. per day and becomes no longer palpable about 1 week after delivery.

At what APGAR score at 5 minutes after birth should resuscitation be initiated? A. 1-3 B. 7-8 C. 9-10 D. 6-7

A. 1-3

When preparing a woman who is 2 days postpartum for discharge, recommendations for which of the following contraceptive methods would be avoided? A. Diaphragm B. Female condom C. Oral contraceptives D. Rhythm method

A. Diaphragm The diaphragm must be fitted individually to ensure effectiveness. Because of the changes to the reproductive structures during pregnancy and following delivery, the diaphragm must be refitted, usually at the 6 weeks' examination following childbirth or after a weight loss of 15 lbs or more. In addition, for maximum effectiveness, spermicidal jelly should be placed in the dome and around the rim. However, spermicidal jelly should not be inserted into the vagina until involution is completed at approximately 6 weeks. Use of a female condom protects thereproductive system from the introduction of semen or spermicides into the vagina and may be used after childbirth. Oral contraceptives may be started within the first postpartum week to ensure suppression of ovulation .

A postpartum primipara asks the nurse, "When can we have sexual intercourse again?" Which of the following would be the nurse's best response? A. "Anytime you both want to." B. "As soon as choose a contraceptive method." C. "When the discharge has stopped and the incision is healed." D. "After your 6 weeks examination."

C. "When the discharge has stopped and the incision is healed."

The nurse instructs a primipara about safety considerations for the neonate. The nurse determines that the client does not understand the instructions when she says: A. "All neonates should be in an approved car seat when in an automobile." B. "It's acceptable to prop the infant's bottle once in a while." C. "Pillows should not be used in the infant's crib." D. "Infants should never be left unattended on an unguarded surface."

B. "It's acceptable to prop the infant's bottle once in a while."

Lochia normally disappears after how many days postpartum? A. 5 days B. 7-10 days C. 18-21 days D. 28-30 days

B. 7-10 days Normally, lochia disappears after 10 days postpartum. What's important to remember is that the color of lochia gets to be lighter (from reddish to whitish) and scantier everyday.

The nurse in the newborn nursery is caring for a preterm infant. Which is the best method the nurse can use to assist the parents with developing attachment behaviors? A. Place family pictures within the infant's view. B. Encourage the parents to touch and speak to their infant. C. Report only positive qualities and progress to the parents. D. Provide information regarding infant development and stimulation

B. Encourage the parents to touch and speak to their infant.

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

B. Every 15 minutes during the first hour and then every 30 minutes for the next two hours

A nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has a saturated a perineal pad in 1 hour. The nurse reports the amount of lochial flow as: A. Excessive B. Heavy C. Light D. Scant

B. Heavy Heavy lochial discharge is a saturated menstrual pad in 1 hour. Option A: Excessive = menstrual pad saturated in 15 minutes. Option C: Light = less than 10 cm on a menstrual pad in 1 hour. Option D: Scant = less than 2.5 cm on a menstrual pad in 1 hour

During the first 4 hours after a male circumcision, assessing for which of the following is the priority? A. Infection B. Hemorrhage C. Discomfort D. Dehydration

B. Hemorrhage

The nurse is aware that a neonate of a mother with diabetes is at risk for what complication? A. Anemia B. Hypoglycemia C. Nitrogen loss D. Thrombosis

B. Hypoglycemia Neonates of mothers with diabetes are at risk for hypoglycemia due to increased insulin levels. During gestation, an increased amount of glucose is transferred to the fetus across the placenta. The neonate's liver cannot initially adjust to the changing glucose levels after birth. This may result in an overabundance of insulin in the neonate, resulting in hypoglycemia.

After 3 days of breast-feeding, a postpartal patient reports nipple soreness. To relieve her discomfort, the nurse should suggest that she: A. Apply warm compresses to her nipples just before feedings B. Lubricate her nipples with expressed milk before feeding C. Dry her nipples with a soft towel after feedings D. Apply soap directly to her nipples, and then rinse

B. Lubricate her nipples with expressed milk before feeding

Oral contraceptive pills are of different types. Which type is most appropriate for mothers who are breastfeeding? A. Estrogen only B. Progesterone only C. Mixed type- estrogen and progesterone D. 21-day pills mixed type

B. Progesterone only

Which of the following assessment findings would lead the nurse to suspect Down syndrome in an infant? A. Small tongue B. Protruding tongue C. Large nose D. Restricted joint movement

B. Protruding tongue

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

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

Which of the following best reflects the frequency of reported postpartum "blues"? A. Between 10% and 45% of all new mothers report some form of postpartum blues B. Between 35% and 50% of all new mothers report some form of postpartum blues C. Between 50% and 85% of all new mothers report some form of postpartum blues D. Between 25% and 70% of all new mothers report some form of postpartum blues

C. Between 50% and 85% of all new mothers report some form of postpartum blues

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

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

Which of the following is true regarding the fontanels of the newborn? A. The anterior is triangular shaped; the posterior is diamond shaped. B. The posterior closes at 18 months; the anterior closes at 8 to 12 weeks. C. The anterior is large in size when compared to the posterior fontanel. D. The anterior is bulging; the posterior appears sunken.

C. The anterior is large in size when compared to the posterior fontanel. The anterior fontanel is larger in size than the posterior fontanel. Additionally, the anterior fontanel, which is diamond shaped, closes at 18 months, whereas the posterior fontanel, which is triangular shaped, closes at 8 to 12 weeks. Neither fontanel should appear bulging, which may indicate increased intracranial pressure, or sunken, which may indicate dehydration.

Which of the following would be an abnormal finding to assess in a mother who's breastfeeding? A. The attachment of the baby to the breast. B. The mother's comfort level with positioning the baby. C. Audible swallowing. D. The baby's lips smacking

D. The baby's lips smacking Assessing the attachment process for breast-feeding should include all of the answers except the smacking of lips. A baby who's smacking his lips isn't well attached and can injure the mother's nipples.

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

D. The client should avoid getting pregnant for 3 months after the vaccine because the vaccine has teratogenic effects

Vasectomy is a procedure done on a male for sterilization. The organ involved in this procedure is: A. Prostate gland B. Seminal vesicle C. Testes D. Vas deferens

D. Vas deferens Vasectomy is a procedure wherein the vas deferens of the male is ligated and cut to prevent the passage of the sperms from the testes to the penis during ejaculation.

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

D. "I need to stop breastfeeding until this condition resolves." In most cases, the mother can continue to breastfeed with both breasts. If the affected breast is too sore, the mother can pump the breast gently. Regular emptying of the breast is important to prevent abscess formation. Antibiotic therapy assists in resolving the mastitis within 24-48 hours. Additional supportive measures include ice packs, breast supports, and analgesics.

While performing physical assessment of a 12 month-old, the nurse notes that the infant's anterior fontanel is still slightly open. Which of the following is the nurse's most appropriate action? A. Notify the physician immediately because there is a problem. B. Perform an intensive neurological examination. C. Perform an intensive developmental examination. D. Do nothing because this is a normal finding for the age

D. Do nothing because this is a normal finding for the age The anterior fontanelle typically closes anywhere between 12 to 18 months of age. Thus, assessing the anterior fontanelle as still being slightly open is a normal finding requiring no further action. Because it is normal finding for this age, notifying he physician or performing additional examinations are inappropriate.

Which of the following characteristics will distinguish a postmature neonate at birth? A. Plenty of lanugo and vernix caseosa B. Lanugo mainly on the shoulders and vernix in the skin folds C. Pinkish skin with good turgor D. Almost leather-like, dry, cracked skin, negligible vernix caseosa

D. Almost leather-like, dry, cracked skin, negligible vernix caseosa

The following are nursing measures to stimulate lactation EXCEPT: A. Frequent regular breast feeding B. Breast pumping C. Breast massage D. Application of cold compress on the breasts

D. Application of cold compress on the breasts To stimulate lactation, warm compress is applied on the breast. Cold application will cause vasoconstriction thus reducing the blood supply consequently the production of milk.

A woman delivers a 3,250 g neonate at 42 weeks' gestation. Which physical finding is expected during an examination if this neonate? A. Abundant lanugo B. Absence of sole creases C. Breast bud of 1-2 mm in diameter D. Leathery, cracked, and wrinkled skin

D. Leathery, cracked, and wrinkled skin

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

D. Lochia rubra

A mother of a term neonate asks what the thick, white, cheesy coating is on his skin. Which correctly describes this finding? A. Lanugo B. Milia C. Nevus flammeus D. Vernix

D. Vernix

An insulin-dependent diabetic delivered a 10-pound male. When the baby is brought to the nursery, the priority of care is to: A. clean the umbilical cord with Betadine to prevent infection B. give the baby a bath C. call the laboratory to collect a PKU screening test D. check the baby's serum glucose level and administer glucose if < 40 mg/dL

D. check the baby's serum glucose level and administer glucose if < 40 mg/dL

The ideal site for vitamin K injection in the newborn is: A. Right upper arm B. Left upper arm C. Either right or left buttocks D. Middle third of the thigh

D. Middle third of the thigh

Neonates of mothers with diabetes are at risk for which complication following birth? A. Atelectasis B. Microcephaly C. Pneumothorax D. Macrosomia

D. Macrosomia

While assessing a newborn with cleft lip, the nurse would be alert that which of the following will most likely be compromised? A. Sucking ability B. Respiratory status C. Locomotion D. GI function

A. Sucking ability

It has been 12 hours since the client's delivery of a newborn. The nurse assesses the client for the process of involution and documents that it is progressing normally when palpation of the client's fundus is at which level? A. At the level of the umbilicus B. One fingerbreadth below the umbilicus C. Two fingerbreadths below the umbilicus D. Midway between the umbilicus and the symphysis pubis

A. At the level of the umbilicus

The nurse is performing an assessment on a postterm infant. Which physical characteristic should the nurse expect to observe in this infant? A. Peeling of the skin B. Smooth soles without creases C. Lanugo covering the entire body D. Vernix that covers the body in a thick laye

A. Peeling of the skin

The nurse teaches a postpartum client about observation of lochia. The nurse determines the client's understanding when the client says that on the second day postpartum, the lochia should be which color? A. Red B. Pink C. White D. Yellow

A. Red

The nurse in the newborn nursery is planning for the admission of a large for gestational age (LGA) infant. In preparing to care for this infant, the nurse should obtain equipment to perform which diagnostic test? A. Serum insulin level B. Heel stick blood glucose C. Rh and ABO blood typing D. Indirect and direct bilirubin levels

B. Heel stick blood glucose

A postpartum nurse has instructed a new mother regarding 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 observation by the nurse indicates that the mother is performing the procedure correctly? A. The mother cleans the ears and then moves to the eyes and the face. B. The mother begins to wash the newborn infant by starting with the eyes and face. C. The mother washes the arms, chest, and back followed by the neck, arms, and face. D. The mother washes the entire newborn infant's body and then washes the eyes, face, and scalp.

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

The nurse is assessing a 3-day-old preterm neonate with a diagnosis of respiratory distress syndrome (RDS). Which assessment finding indicates that the neonate's respiratory status is improving? A. Edema of the hands and feet B. Urine output of 3 mL/kg/hour C. Presence of a systolic murmur D. Respiratory rate between 60 and 70 breaths per minute

B. Urine output of 3 mL/kg/hour

The nurse is discussing contraceptive methods with a postpartum client. The nurse tells the client that combined oral contraceptives are contraindicated if the client has a medical history of which conditions? Select all that apply. A. Acne B. Infertility C. Breast cancer D. Dysmenorrhea E. Coronary artery disease F. Thromboembolic disorders

C, E, F

A 10-day postpartum breast-feeding client telephones the postpartum unit complaining of a reddened, painful breast and elevated temperature. Based on assessment of the client's complaints, which action should the nurse tell the client to do? A. "Breast-feed only with the unaffected breast." B. "Stop breast-feeding because you probably have an infection." C. "Notify your health care provider because you may need medication." D. "Continue breast-feeding because this is a normal response in breast-feeding mothers."

C. "Notify your health care provider because you may need medication." Based on the signs and symptoms presented by the client (particularly the elevated temperature), the health care provider needs to be notified because an antibiotic that is tolerated by the infant, as well as the mother, may be prescribed. The mother should continue to nurse on both breasts, but should start the infant on the unaffected breast while the affected breast lets down

The nurse is checking the fundus of a postpartum woman and notes that the uterus is soft and spongy. Which nursing action is appropriate initially? A. Notify the health care provider. B. Encourage the mother to ambulate. C. Massage the fundus gently until it is firm. D. Document fundal position, consistency, and height

C. Massage the fundus gently until it is firm.

The nurse determines that a client understands the purpose of a phytonadione (vitamin K) injection for her newborn if the client states that vitamin K is administered for which purpose? A. Newborns lack vitamins. B. Newborns have low blood levels. C. Newborns lack intestinal bacteria. D. Newborns cannot produce vitamin K in the liver.

C. Newborns lack intestinal bacteria.

The nurse is caring for a term infant who is 24 hours old who had a confirmed episode of hypoglycemia when 1 hour old. Which observation by the nurse would indicate the need for follow-up? A. Weight loss of 4 ounces and dry, peeling skin B. Blood glucose level of 40 mg/dL before the last feeding C. Breast-feeding for 20 minutes or more, with strong sucking D. High-pitched cry, drinking 10 to 15 mL of formula per feeding

D. High-pitched cry, drinking 10 to 15 mL of formula per feeding Hypoglycemia causes central nervous system symptoms (high-pitched cry), and it is also exhibited by a lack of strength for eating enough for growth. At 24 hours old, a term infant should be able to consume at least 1 ounce of formula per feeding. A high-pitched cry is indicative of neurological involvement. Weight loss over the first few days of life and dry, peeling skin are normal findings for term infants. Blood glucose levels are acceptable at 40 mg/dL during the first few days of life. Breast-feeding for 20 minutes with a strong suck is an excellent finding

A hepatitis B screen is performed on a postpartum client and the results indicate the presence of antigens in the maternal blood. Which intervention should the nurse anticipate to be prescribed to protect the neonate? A. Obtain serum liver enzymes. B. Repeat hepatitis B screen in 1 week. C. Administer antibiotics during pregnancy. D. Administer hepatitis vaccine and hepatitis B immune globulin to the neonate.

D. Administer hepatitis vaccine and hepatitis B immune globulin to the neonate.

The nurse is monitoring a preterm newborn infant for manifestations of respiratory distress syndrome (RDS). The nurse should monitor the infant for which manifestations? A. Acrocyanosis, emphysema, and interstitial edema B. Acrocyanosis, apnea, pneumothorax, and grunting C. Barrel-shaped chest, acrocyanosis, and bradycardia D. Cyanosis, tachypnea, retractions, grunting respirations, and nasal flaring

D. Cyanosis, tachypnea, retractions, grunting respirations, and nasal flaring

The nurse is caring for a postpartum client. Which finding should make the nurse suspect endometritis in this client? A. Breast engorgement B. Elevated white blood cell count C. Lochia rubra on the second day postpartum D. Fever over 38°C (100.4º F), beginning 2 days postpartum

D. Fever over 38° C (100.4º F), beginning 2 days postpartum Endometritis is a common cause of postpartum infection. The presence of fever of 38° C or more on 2 successive days of the first 10 postpartum days (not counting the first 24 hours after birth) is indicative of a postpartum infection. Breast engorgement is a normal response in the postpartum period and is not associated with endometritis. The white blood cell count of a postpartum woman is normally elevated; thus, this method of detecting infection is not of great value in the puerperium. Lochia rubra on the second day postpartum is a normal finding.

The nurse is teaching umbilical cord care to a new mother. What information should the nurse provide to the mother related to cord care? A. Alcohol is the only agent to use to clean the cord. B. Cord care is done only at birth to control bleeding. C. It takes at least 21 days for the cord to dry up and fall off. D. The process of keeping the cord clean and dry will decrease bacterial growth.

D. The process of keeping the cord clean and dry will decrease bacterial growth. The cord should be kept clean and dry to decrease bacterial growth. It should be cleansed two to three times a day with a prescribed agent. Usually the cord is cleansed with soap and water around base of the cord where it joins the skin. The health care provider is notified of any odor, discharge, or skin inflammation. The diaper should not cover the cord because a wet or soiled diaper will slow or prevent drying of the cord and foster infection. Cord care is required until the cord dries up and falls off between 7 and 14 days after birth

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

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

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

A. Assess for hypovolemia and notify the health care provider

A newborn has small, whitish, pinpoint spots over the nose, which the nurse knows are caused by retained sebaceous secretions. When charting this observation, the nurse identifies it as: A. Milia B. Lanugo C. Whiteheads D. Mongolian spots

A. Milia

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

B. Rapid diuresis

Which of the following when present in the urine may cause a reddish stain on the diaper of a newborn? A. Mucus B. Uric acid crystals C. Bilirubin D. Excess iron

B. Uric acid crystals

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

C. Days 10-14 PP On the third and fourth PP days, the lochia becomes a pale pink or brown and contains old blood, serum, leukocytes, and tissue debris. This type of lochia usually lasts until PP day 10. Lochia rubra usually last for the first 3 to 4 days PP. Lochia alba, which contain leukocytes, decidua, epithelial cells, mucus, and bacteria, may continue for 2 to 6 weeks PP.

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

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

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

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

All of the following are important in the immediate care of the premature neonate. Which nursing activity should have the greatest priority? A. Instillation of antibiotic in the eyes B. Identification by bracelet and foot prints C. Placement in a warm environment D. Neurological assessment to determine gestational age

C. Placement in a warm environment

Which neonatal behavior is most commonly associated with fetal alcohol syndrome (FAS)? A. Hypoactivity B. High birth weight C. Poor wake and sleep patterns D. High threshold of stimulation

C. Poor wake and sleep patterns Altered sleep patterns are caused by disturbances in the CNS from alcohol exposure in utero. Hyperactivity is a characteristic generally noted. Low birth weight is a physical defect seen in neonates with FAS. Neonates with FAS generally have a low threshold for stimulation.

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

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

Normal lochial findings in the first 24 hours post-delivery include: A. Bright red blood B. Large clots or tissue fragments C. Pinkish-brown blood D. The complete absence of lochia

A. Bright red blood

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

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

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

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

When the nurse on duty accidentally bumps the bassinet, the neonate throws out its arms, hands opened, and begins to cry. The nurse interprets this reaction as indicative of which of the following reflexes? A. Moro reflex B. Babinski reflex C. Grasping reflex D. Tonic neck reflex

A. Moro reflex

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

A. Peripheral vascular disease This medication is avoided in clients with significant cardiovascular disease, peripheral disease, hypertension, eclampsia, or preeclampsia. These conditions are worsened by the vasoconstriction effects of this medication.

Which of the following actions demonstrates the nurse's understanding about the newborn's thermoregulatory ability? A. Placing the newborn under a radiant warmer. B. Suctioning with a bulb syringe C. Obtaining an Apgar score D. Inspecting the newborn's umbilical cord

A. Placing the newborn under a radiant warmer.

The post term neonate with meconium-stained amniotic fluid needs care designed to especially monitor for which of the following? A. Respiratory problems B. Gastrointestinal problems C. Integumentary problems D. Elimination problems

A. Respiratory problems Intrauterine anoxia may cause relaxation of the anal sphincter and emptying of meconium into the amniotic fluid. At birth some of the meconium fluid may be aspirated, causing mechanical obstruction or chemical pneumonitis. The infant is not at increased risk for gastrointestinal problems. Even though the skin is stained with meconium, it is noninfectious (sterile) and nonirritating. The postterm meconium-stained infant is not at additional risk for bowel or urinary problems.

When newborns have been on formula for 36-48 hours, they should have a: A. Screening for PKU B. Vitamin K injection C. Test for necrotizing enterocolitis D. Heel stick for blood glucose level

A. Screening for PKU By now the newborn will have ingested an ample amount of the amino acid phenylalanine, which, if not metabolized because of a lack of the liver enzyme, can deposit injurious metabolites into the bloodstream and brain; early detection can determine if the liver enzyme is absent.

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

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

The normal respiration of a newborn immediately after birth is characterized as: A. Shallow and irregular with short periods of apnea lasting not longer than 15 seconds, 30-60 breaths per minute B. 20-40 breaths per minute, abdominal breathing with active use of intercostals muscles C. 30-60 breaths per minute with apnea lasting more than 15 seconds, abdominal breathing D. 30-50 breaths per minute, active use of abdominal and intercostal muscles

A. Shallow and irregular with short periods of apnea lasting not longer than 15 seconds, 30-60 breaths per minute A newly born baby still is adjusting to extra uterine life and the lungs are just beginning to function as a respiratory organ. The respiration of the baby at this time is characterized as usually shallow and irregular with short periods of apnea, 30-60 breaths per minute. The apneic periods should be brief lasting not more than 15 seconds otherwise it will be considered abnormal.

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

A. Soft, non-tender; colostrum is present Breasts are essentially unchanged for the first two to three days after birth. Colostrum is present and may leak from the nipples.

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

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

Which of the following describes the Babinski reflex? A. The newborn's toes will hyperextend and fan apart from dorsiflexion of the big toe when one side of foot is stroked upward from the ball of the heel and across the ball of the foot. B. The newborn abducts and flexes all extremities and may begin to cry when exposed to sudden movement or loud noise. C. The newborn turns the head in the direction of stimulus, opens the mouth, and begins to suck when cheek, lip, or corner of mouth is touched. D. The newborn will attempt to crawl forward with both arms and legs when he is placed on his abdomen on a flat surface

A. The newborn's toes will hyperextend and fan apart from dorsiflexion of the big toe when one side of foot is stroked upward from the ball of the heel and across the ball of the foot

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

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

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

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

The nurse admits a newborn to the nursery. On assessment of the newborn, the nurse palpates the anterior fontanel and notes that it feels soft. The nurse determines that this finding indicates which condition? A. Dehydration B. A normal finding C. Increased intracranial pressure D. Decreased intracranial pressure

B. A normal finding

Right after birth, when the skin of the baby's trunk is pinkish but the soles of the feet and palm of the hands are bluish this is called: A. Syndactyly B. Acrocyanosis C. Peripheral cyanosis D. Cephalo-caudal cyanosis

B. Acrocyanosis

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

B. An increase in the pulse from 88 to 102 BPM During the 4th stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. A rising pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. The blood pressure will fall as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage. A slight rise in temperature is normal. The respiratory rate is increased slightly.

Which of the following is an abnormal vital sign in postpartum? A. Pulse rate between 50-60/min B. BP diastolic increase from 80 to 95 mmHg C. BP systolic between 100-120 mmHg D. Respiratory rate of 16-20/min

B. BP diastolic increase from 80 to 95 mmHg

Methergine is prescribed for a woman to treat PP hemorrhage. Before administration of this medication, the priority nursing assessment is to check the: A. Amount of lochia B. Blood pressure C. Deep tendon reflexes D. Uterine tone

B. Blood pressure

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

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

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

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

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

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

A nurse in the newborn nursery is monitoring a preterm newborn infant for respiratory distress syndrome. Which assessment signs if noted in the newborn infant would alert the nurse to the possibility of this syndrome? A. Hypotension and Bradycardia B. Tachypnea and retractions C. Acrocyanosis and grunting D. The presence of a barrel chest with grunting

B. Tachypnea and retractions The infant with respiratory distress syndrome may present with signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts.

Which of the following behaviors would indicate that a client was bonding with her baby? A. The client asks her husband to give the baby a bottle of water. B. The client talks to the baby and picks him up when he cries. C. The client feeds the baby every three hours. D. The client asks the nurse to recommend a good child care manual.

B. The client talks to the baby and picks him up when he cries.

A nurse prepares to administer a vitamin K injection to a newborn infant. The mother asks the nurse why her newborn infant needs the injection. The best response by the nurse would be: A. "You infant needs vitamin K to develop immunity." B. "The vitamin K will protect your infant from being jaundiced." C. "Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding." D. "Newborn infants have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel."

C. "Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding."

The nurse plans to instruct the postpartum client about methods to prevent breast engorgement. Which of the following measures would the nurse include in the teaching plan? A. Feeding the neonate a maximum of 5 minutes per side on the first day B. Wearing a supportive brassiere with nipple shields C. Breast-feeding the neonate at frequent intervals D. Decreasing fluid intake for the first 24 to 48 hours

C. Breast-feeding the neonate at frequent intervals

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

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

Which of the following is the priority focus of nursing practice with the current early postpartum discharge? A. Promoting comfort and restoration of health B. Exploring the emotional status of the family C. Facilitating safe and effective self-and newborn care D. Teaching about the importance of family planning

C. Facilitating safe and effective self-and newborn care

When teaching umbilical cord care to a new mother, the nurse would include which information? A. Apply peroxide to the cord with each diaper change B. Cover the cord with petroleum jelly after bathing C. Keep the cord dry and open to air D. Wash the cord with soap and water each day during a tub bath

C. Keep the cord dry and open to air

A nurse in a newborn nursery is performing an assessment of a newborn infant. The nurse is preparing to measure the head circumference of the infant. The nurse would most appropriately: A. Wrap the tape measure around the infant's head and measure just above the eyebrows. B. Place the tape measure under the infants head at the base of the skull and wrap around to the front just above the eyes C. Place the tape measure under the infants head, wrap around the occiput, and measure just above the eyes D. Place the tape measure at the back of the infant's head, wrap around across the ears, and measure across the infant's mouth

C. Place the tape measure under the infants head, wrap around the occiput, and measure just above the eyes To measure the head circumference, the nurse should place the tape measure under the infant's head, wrap the tape around the occiput, and measure just above the eyebrows so that the largest area of the occiput is included.

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

C. Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn One week after birth the woman should exhibit behaviors characteristic of the taking-hold stage as described in response 3. This stage lasts for as long as 4 to 5 weeks after birth. Responses 1 and 2 are characteristic of the taking-in stage, which lasts for the first few days after birth. Response 4 reflects the letting-go stage, which indicates that psychosocial recovery is complete.

Soon after delivery a neonate is admitted to the central nursery. The nursery nurse begins the initial assessment by A. auscultate bowel sounds. B. determining chest circumference C. inspecting the posture, color, and respiratory effort D. checking for identifying birthmarks

C. inspecting the posture, color, and respiratory effort

A neonate has been diagnosed with caput succedaneum. Which statement is correct about this condition? A. "It usually resolves in 3-6 weeks." B. "It doesn't cross the cranial suture line." C. "It's a collection of blood between the skull and the periosteum." D. "It involves swelling of tissue over the presenting part of the presenting head."

D. "It involves swelling of tissue over the presenting part of the presenting head." Caput succedaneum is the swelling of tissue over the presenting part of the fetal scalp due to sustained pressure; it resolves in 3-4 days.

A newborn's mother is alarmed to find small amounts of blood on her infant girl's diaper. When the nurse checks the infant's urine it is straw colored and has no offensive odor. Which explanation to the newborn's mother is most appropriate? A. "It appears your baby has a kidney infection" B. "Breast-fed babies often experience this type of bleeding problem due to lack of vitamin C in the breast milk" C. "The baby probably passed a small kidney stone" D. "Some infants experience menstruation like bleeding when hormones from the mother are not available"

D. "Some infants experience menstruation like bleeding when hormones from the mother are not available"

The nurse assesses the postpartum vaginal discharge (lochia) on four clients. Which of the following assessments would warrant notification of the physician? A. A dark red discharge on a 2-day postpartum client B. A pink to brownish discharge on a client who is 5 days postpartum C. Almost colorless to creamy discharge on a client 2 weeks after delivery D. A bright red discharge 5 days after delivery

D. A bright red discharge 5 days after delivery Any bright red vaginal discharge would be considered abnormal, but especially 5 days after delivery, when the lochia is typically pink to brownish. Lochia rubra, a dark red discharge, is present for 2 to 3 days after delivery. Bright red vaginal bleeding at this time suggests late postpartum hemorrhage, which occurs after the first 24 hours following delivery and is generally caused by retained placental fragments or bleeding disorders. Lochia rubra is the normal dark red discharge occurring in the first 2 to 3 days after delivery, containing epithelial cells, erythrocyes, leukocytes and decidua. Lochia serosa is a pink to brownish serosanguineous discharge occurring from 3 to 10 days after delivery that contains decidua, erythrocytes, leukocytes, cervical mucus, and microorganisms. Lochia alba is an almost colorless to yellowish discharge occurring from 10 days to 3 weeks after delivery and containing leukocytes, decidua, epithelial cells, fat, cervical mucus, cholesterol crystals, and bacteria.

Which of the following would the nurse in charge do first after observing a 2-cm circle of bright red bleeding on the diaper of a neonate who just had a circumcision? A. Notify the neonate's pediatrician immediately B. Check the diaper and circumcision again in 30 minutes C. Secure the diaper tightly to apply pressure on the site D. Apply gentle pressure to the site with a sterile gauze pad

D. Apply gentle pressure to the site with a sterile gauze pad

Before assessing the postpartum client's uterus for firmness and position in relation to the umbilicus and midline, which of the following shouldthe nurse do first? A. Assess the vital signs B. Administer analgesia C. Ambulate her in the hall D. Assist her to urinate

D. Assist her to urinate

When caring for a 3-day-old neonate who is receiving phototherapy to treat jaundice, the nurse in charge would expect to do which of the following? A. Turn the neonate every 6 hours B. Encourage the mother to discontinue breast-feeding C. Notify the physician if the skin becomes bronze in color D. Check the vital signs every 2 to 4 hours

D. Check the vital signs every 2 to 4 hours

A postpartum nurse is providing instructions to the mother of a newborn infant with hyperbilirubinemia who is being breastfed. The nurse provides which most appropriate instructions to the mother? A. Switch to bottle feeding the baby for 2 weeks B. Stop the breast feedings and switch to bottle-feeding permanently C. Feed the newborn infant less frequently D. Continue to breastfeed every 2-4 hours

D. Continue to breastfeed every 2-4 hours

When performing nursing care for a neonate after a birth, which intervention has the highest nursing priority? A. Obtain a blood glucose reading B. Give the initial bath C. Give the vitamin K injection D. Cover the neonates head with a cap

D. Cover the neonates head with a cap Covering the neonates head with a cap helps prevent cold stress due to excessive evaporative heat loss from the neonate's wet head. Vitamin K can be given up to 4 hours after birth.

The nurse assesses the vital signs of a client, 4 hours' postpartum that are as follows: BP 90/60; temperature 100.4ºF; pulse 100 weak, thready; R 20 per minute. Which of the following should the nurse do first? A. Report the temperature to the physician B. Recheck the blood pressure with another cuff C. Assess the uterus for firmness and position D. Determine the amount of lochia

D. Determine the amount of lochia A weak, thready pulse elevated to 100 BPM may indicate impending hemorrhagic shock. An increased pulse is a compensatory mechanism of the body in response to decreased fluid volume. Thus, the nurse should check the amount of lochia present. Temperatures up to 100.48F in the first 24 hours after birth are related to the dehydrating effects of labor and are considered normal. Although rechecking the blood pressure may be a correct choice of action, it is not the first action that should be implemented in light of the other data. The data indicate a potential impending hemorrhage. Assessing the uterus for firmness and position in relation to the umbilicus and midline is important, but the nurse should check the extent of vaginal bleeding first. Then it would be appropriate to check the uterus, which may be a possible cause of the hemorrhage.

A nurse in a delivery room is assisting with the delivery of a newborn infant. After the delivery, the nurse prepares to prevent heat loss in the newborn resulting from evaporation by: A. Warming the crib pad B. Turning on the overhead radiant warmer C. Closing the doors to the room D. Drying the infant in a warm blanket

D. Drying the infant in a warm blanket Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn infant will prevent hypothermia via evaporation.

Which of the following amounts of blood loss following birth marks the criterion for describing postpartum hemorrhage after a vaginal delivery? A. More than 200 ml B. More than 300 ml C. More than 400 ml D. More than 500 ml

D. More than 500 ml

One hour following a normal vaginal delivery, a newborn infant boy's axillary temperature is 96° F, his lower lip is shaking and, when the nurse assesses for a Moro reflex, the boy's hands shake. Which intervention should the nurse implement first? A. Stimulate the infant to cry. B. Wrap the infant in warm blankets. C. Feed the infant formula. D. Obtain a serum glucose level.

D. Obtain a serum glucose level. This infant is demonstrating signs of hypoglycemia, possibly secondary to a low body temperature. The nurse should first determine the serum glucose level (D). (A) is an intervention for a lethargic infant. (B) should be done based on the temperature, but first the glucose level should be obtained. (C) helps raise the blood sugar, but first the nurse should determine the glucose level.

A healthy term neonate born by C-section was admitted to the transitional nursery 30 minutes ago and placed under a radiant warmer. The neonate has an axillary temperature of 99.5º F, a respiratory rate of 80 breaths/minute, and a heel stick glucose value of 60 mg/dl. Which action should the nurse take? A. Wrap the neonate warmly and place her in an open crib B. Administer an oral glucose feeding of 10% dextrose in water C. Increase the temperature setting on the radiant warmer D. Obtain an order for IV fluid administration

D. Obtain an order for IV fluid administration Assessment findings indicate that the neonate is in respiratory distress—most likely from transient tachypnea, which is common after cesarean delivery. A neonate with a rate of 80 breaths a minute shouldn't be fed but should receive IV fluids until the respiratory rate returns to normal. To allow for close observation for worsening respiratory distress, the neonate should be kept unclothed in the radiant warmer.

A female adult patient is taking a progestin-only oral contraceptive, or mini pill. Progestin use may increase the patient's risk for: A. Endometriosis B. Female hypogonadism C. Premenstrual syndrome D. Ovarian cysts

D. Ovarian cysts

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

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

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

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

When performing a newborn assessment, the nurse should measure the vital signs in the following sequence: A. Pulse, BP, respirations, temperature B. Temperature, pulse, BP, respirations C. Respirations, temperature, pulse, BP D. Respirations, pulse, BP, temperature

D. Respirations, pulse, BP, temperature

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

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

The home health nurse visits the Cox family 2 weeks after hospital discharge. She observes that the umbilical cord has dried and fallen off. The area appears healed with no drainage or erythema present. The mother can be instructed to: A. cover the umbilicus with a band-aid. B. continue to clean the stump with alcohol for one week. C. apply an antibiotic ointment to the stump D. give him a bath in an infant tub now

D. give him a bath in an infant tub now