CH 28 Care of Newborn/Mother Test 2 Flashcards
When assessing a mother 12 hours following the delivery of a baby, where should the nurse expect to palpate the fundus?
a. 2 cm below the umbilicus
b. At the umbilicus
c. 1 cm below the umbilicus
d. Halfway between the umbilicus and the symphysis pubis
ANS: B
Within 12 hours, the fundus rises to the level of the umbilicus. The fundus should be firm. Immediately following delivery, the fundus will be felt halfway between the umbilicus and the symphysis.
What is the name of the vaginal discharge that occurs immediately following delivery?
a. Lochia serosa
b. Lochia rubra
c. Lochia palatine
d. Lochia alba
ANS: B
The vaginal discharge that occurs immediately following discharge is known as lochia rubra and is made up mostly of blood. As the placenta heals, the draining turns pink to dark brown in color and is known as lochia serosa. After about 7 days, the discharge turns slight yellow to white and is called lochia alba.
What is the first secretion produced by the breast?
a. Prolactin
b. Colostrum
c. False milk
d. Whey
ANS: B
The first secretion to be produced by the breast is colostrum.
What should be included in a teaching plan regarding breast engorgement?
a. It typically occurs on the first postpartum day.
b. It is usually first observed in the axillary region.
c. It occurs only in women who are not breastfeeding.
d. It occurs near the nipple on the third postpartum day.
ANS: B
Filling of the breast with milk (engorgement) usually begins in the axillary region on the third postpartum day when the milk comes in. It occurs regardless of whether the mother is breastfeeding or bottle-feeding.
When is breast engorgement most likely to occur?
a. When the infant’s mouth surrounds the areola when feeding
b. When the breast tissue becomes congested
c. When the breast is emptied completely at each feeding
d. When the infant’s mouth grasps the nipple firmly
ANS: B
Engorgement is the result of venous and lymphatic stasis (congestion). Emptying the breast at each feeding, the infant grasping the nipple firmly, and the infant’s mouth surrounding the areola when feeding are all measures that will aid in decreasing engorgement.
Which statement would be a correct description of colostrum?
a. Slightly yellow and low in protein
b. Slightly yellow and provides antibodies
c. Creamy and high in fat and protein
d. Colorless and high in fat and carbohydrates
ANS: B
Colostrum is slightly yellow in color and is rich in antibodies.
The new mother has decided not to breastfeed the baby. How should the nurse correctly instruct the mother to suppress her milk supply?
a. Pump the breasts to remove milk
b. Apply warm, moist compresses
c. Restrict oral fluids
d. Apply a firm bra and ice packs
ANS: D
If a patient is not breastfeeding, compress the breasts with a firm bra and wrapped ice packs to suppress the milk supply. Pumping the breasts and applying warm, moist compresses are instructions for the breast-feeding mother to deal with the painful symptoms of engorgement.
During the immediate postpartum period, the mother has a temperature of 100.2°F (37.8°C), pulse 52, respirations 18, BP 138/84. What should the nurse do?
a. Report the temperature as abnormal.
b. Continue to monitor every 15 minutes.
c. Report the pulse as abnormal.
d. Nothing as the vital signs are normal.
ANS: D
The vital signs are normal for a new postpartum patient.
Within the first hour following a vaginal delivery, the nurse assesses the mother and finds the fundus is firm and there is a trickle of bright red blood. What should be the nurse’s reaction to the assessment?
a. This is a normal occurrence.
b. This is abnormal and should be reported.
c. The patient should be administered a blood thinner.
d. The patient should be restricted to bed rest.
ANS: A
A bright red drainage is normal immediately after delivery. The patient should be monitored at regular intervals. Bed rest is not indicated. A blood thinner would not be given.
What is the appropriate way to assess the fundus of the postpartum patient?
a. Using the side of one hand moving down from the umbilicus
b. Using one hand over the lower segment of the uterus
c. Using one hand pushing upward from the lower uterus
d. Using one hand on the lower uterine segment while the other hand locates the fundus of the uterus
ANS: D
The proper way to assess the fundus of a mother who has just given birth is by placing one hand on the lower uterine segment while the other hand locates the fundus of the uterus.
The postpartum mother with a third degree laceration tells the nurse she is afraid to have a bowel movement because of her painful episiotomy. What should the nurse do?
a. Offer a suppository or enema.
b. Encourage ambulation.
c. Offer stool softeners as prescribed.
d. Offer pain medication before defecating.
ANS: C
Stool softeners are available to ease the pain of defecation caused by hemorrhoids and birth trauma. Suppositories or enemas are contraindicated in mothers with third or fourth degree lacerations. Pain medications can often cause constipation. Ambulation may aid in defecation, but will not soften the stool.
A new mother had spinal anesthesia during a cesarean delivery. She now has a desire to void and can wiggle her toes. What should be the nurse’s response when the mother asks to go the bathroom?
a. Assess her blood pressure.
b. Obtain a wheelchair.
c. Palpate her bladder.
d. Put slippers on her feet.
ANS: D
The nurse should check that the mother is wearing slippers to ensure better footing. If the mother has a desire to void and can move her toes, there is no need for her to remain bedridden.
A mother delivered her baby at midnight and it is now 9 a.m. She wants to sleep and asks the nurse to take care of the baby. What is this considered?
a. Fatigue from labor
b. Normal “taking in” response
c. Abnormal “taking in” response
d. Risk for altered maternal-infant bonding
ANS: B
Her primary focus will be on her own needs such as sleep (“taking in” stage).
Which of the following would be considered a normal assessment finding in a 1-day postpartum patient?
a. Pinkish to brown lochia
b. Voiding frequently 50 to 75 mL of urine
c. Complaining of “after pains”
d. Fundus 1 cm above the umbilicus
ANS: C
The common discomfort of after pains is a normal assessment finding at 1-day postpartum. The normal discharge 1-day postpartum would be lochia rubra, which is made up of mostly blood. The fundus would be palpated at the level of the umbilicus. Frequent voiding would be considered abnormal.
A new Native American mother tells the nurse that when she goes home, her mother-in-law will be caring for the baby while she rests. The nurse has concerns. What should the nurse do?
a. Explain the importance of ambulating to recover.
b. Explain the importance of maternal-infant bonding.
c. Explore ways to blend this with safe health teaching.
d. Encourage this cultural behavior.
ANS: C
Follow principles that facilitate nursing practice within transcultural situations.
Before initially feeding an infant, what reflex should the nurse assess?
a. Moro reflex
b. Rooting reflex
c. Babinski reflex
d. Swallow reflex
ANS: D
The nurse should verify that the infant is able to swallow normally before feeding.
Following delivery of the newborn, which nursing intervention should be carried out immediately?
a. Weigh the infant.
b. Warm the infant.
c. Bathe the infant.
d. Inoculate the infant.
ANS: B
Maintenance of body temperature is the primary concern when caring for the newborn. The infant will also be weighed, bathed, and inoculated, but those measures are not the primary concern.
Where would acrocyanosis be assessed on a newborn?
a. Circumoral area
b. Brow
c. Feet
d. Mucous membrane
ANS: C
Acrocyanosis is the slightly blue appearance of the hands and feet that is caused by poor circulation. It can last for 7 to 10 days in the newborn.
The nurse identifies that the newborn is jaundiced within the first 24 hours of birth, with jaundice occurring over bony prominences of the face and the mucous membrane. What type of jaundice does this represent?
a. Physiologic
b. Normal
c. Pathologic
d. Transitory
ANS: C
Jaundice that appears within the first 48 hours of life is termed pathologic jaundice and is abnormal. Pathologic jaundice indicates excessive red blood cell destruction and it should be reported. Jaundice that appears after the first 48 hours of life is known as physiologic jaundice and is considered normal.
What is the term for the cream cheese–like substance that protects the infant’s skin from amniotic fluid?
a. Lanugo
b. Meconium
c. Desquamation
d. Vernix caseosa
ANS: D
At birth, the skin is covered with a yellowish-white cream cheese–like substance called vernix caseosa.
Which tests are performed to detect inborn errors of metabolism in the newborn?
a. Blood glucose
b. Phenylketonuria (PKU)
c. Blood urea nitrogen (BUN)
d. Prothrombin time (PT)
ANS: B
State law requires certain diagnostic tests be performed on the newborn, including PKU, which detects an inborn error of metabolism.
Which newborn assessment finding can suggest a chromosomal disorder?
a. Epstein pearls
b. Gynecomastia
c. Babinski reflex
d. Simian crease
ANS: D
A simian crease may indicate a chromosomal disorder.
Why is vitamin K given by injection to the newborn?
a. Most mothers have a vitamin K deficiency that develops during pregnancy.
b. Bacteria that synthesize vitamin K are not present in newborns.
c. Vitamin K prevents the synthesis of prothrombin.
d. The newborn does not store vitamin K.
ANS: B
Newborns are not able to synthesize vitamin K in the colon until they have adequate intestinal flora, therefore, the vitamin K injection is given as a prevention measure against hemorrhage.
What should be included when discussing the care of a circumcised infant after discharge from the hospital?
a. Gently remove the yellow exudate from the foreskin.
b. Apply sterile petroleum gauze after each diaper change.
c. Wipe the circumcision with alcohol each day.
d. Avoid the use of cloth diapers until the foreskin has healed.
ANS: B
Wash the penis at diaper change and apply sterile petroleum gauze. The yellow exudate should not be removed as it is part of the normal healing process. The circumcised area should be cleansed gently, not with alcohol. Cloth diapers are sometimes recommended to promote healing.
