Chapter 28 Care Of The Mother And Newborn

Question 1

When the let-down reflex occurs, which action would the nurse perform?

1. Offer the mother oral fluids to prevent dehydration.
2. Assess the color change and consistency of the lochia.
3. Assist the mother with breastfeeding as needed.
4. Observe for frequency of saturation of perineal pads.

Answer 1

3. Assist the mother with breastfeeding as needed.

Rational

The let-down reflex, also known as the milk ejection reflex, is a natural response to breastfeeding where milk is released from the breast. When this reflex occurs, the primary concern is to assist the mother with breastfeeding. This involves ensuring that the baby is properly latched onto the breast and that the mother is comfortable, which facilitates successful breastfeeding.

Question 2

The nurse is monitoring the flow of lochia for several postpartum patients. Which condition is cause for the greatest concern?

1. There is a gush of dark lochia as the patient gets out of bed.
2. Lochia alba changes back to lochia rubra.
3. Pad with scant lochia serosa has a fleshy smell.
4. One pad is saturated in 20 minutes with lochia rubra.

Answer 2

4. One pad is saturated in 20 minutes with lochia rubra.

Rational

4. Saturating one pad in 20 minutes with lochia rubra is concerning for excessive bleeding, indicating possible hemorrhage.

The most concerning condition is option 4, as it suggests a high risk of postpartum hemorrhage, which requires immediate medical attention.

Question 3

The nurse hears in report that the woman had a cesarean birth with general anesthesia. The combination of general anesthesia and lost abdominal tone prompts the nurse to be watchful for which potential complication?

1. Paralytic ileus
2. Hyperemesis
3. Loss of sensation in legs
4. Urinary incontinence

Answer 3

1. Paralytic ileus

Rational

The question is asking about a potential complication that can arise from the combination of general anesthesia and loss of abdominal tone following a cesarean birth.

1. Paralytic ileus: General anesthesia can slow down intestinal motility, and the loss of abdominal tone can exacerbate this issue, leading to a condition called paralytic ileus, where the intestines do not move normally.

Question 4

The mother has lost a large volume of blood and appears to be in hypovolemic shock following the delivery. Which action would the nurse perform?

1. Raise the head of the bed to 80 degrees.
2. Discontinue the oxytocic agent in the intravenous infusion.
3. Provide skin-to-skin contact with newborn.
4. Provide oxygen by face mask at 8-10 L/ min.

Answer 4

4. Provide oxygen by face mask at 8-10 L/ min.

Rational

In the scenario described, the mother is experiencing hypovolemic shock, which is a condition where there is a severe loss of blood leading to inadequate blood flow to organs. The primary actions in managing hypovolemic shock are to ensure adequate oxygenation and support circulation.

4. Providing oxygen by face mask at 8-10 L/min is an appropriate action because it helps increase oxygen delivery to tissues and organs, which is crucial in managing shock.

Question 5

Which action by the mother indicates a need for additional teaching about the care of the infant’s umbilicus?

1. Gives a tub bath in the first 3 days after delivery
2. Uses alcohol on the stump daily
3. Folds the diaper down from the umbilicus
4. Reports a foul odor or redness from the stump

Answer 5

1. Gives a tub bath in the first 3 days after delivery

Rational

1. Gives a tub bath in the first 3 days after delivery: This is not recommended because the umbilical stump needs to stay dry to promote healing and prevent infection. Giving a tub bath could wet the stump and delay healing.

Question 6

In teaching the new mother about breastfeed-ing, what would the nurse tell her?

1. Use one breast for two consecutive feedings.
2. Have the baby nurse for 5 minutes at each breast.
3. Put as much of the areolar tissue into the baby’s mouth as possible.
4. Pull the breast straight away from the baby’s mouth to break the suction seal.

Answer 6

3. Put as much of the areolar tissue into the baby’s mouth as possible.

Rational

3. Ensuring that as much of the areolar tissue is in the baby’s mouth as possible helps the baby latch properly. A good latch is crucial for effective breastfeeding and prevents nipple soreness.

Question 7

The nurse is teaching the patient about the signs and symptoms that should be reported to the health care provider (HCP). After 5 days from the delivery date, which sign/ symptom warrants contacting the HCP?

1. Temperature is 99° F.
2. Lochia is light pink-brown in color.
3. Breast is tender and red.
4. Fundus feels like a softball.

Answer 7

3. Breast is tender and red.

Rational

3. Breast is tender and red. - This can indicate mastitis, an infection of the breast tissue. It is a serious condition that requires contacting a healthcare provider for potential treatment with antibiotics.

Question 8

The home health nurse is assessing the mother’s peripads 6 days after delivery. What is the expected finding?

1. Bright-red blood with tissue
2. Thin pinkish-brown drainage
3. Slightly yellow to white drainage
4. Small clots with a fleshy odor

Answer 8

2. Thin pinkish-brown drainage

Rational

In the postpartum period, lochia refers to the vaginal discharge after giving birth, which changes in color and consistency as the days progress.

2. Thin pinkish-brown drainage is expected around 4 to 10 days postpartum (lochia serosa).

At 6 days postpartum, the expected finding is typically thin pinkish-brown drainage, which corresponds to lochia serosa.

Question 9

The nurse is explaining to a mother who had an episiotomy how to use a squeeze bottle to clean herself after urination or a bowel move-ment. Which information is correct?

1. “First, clean perineal area front to back with toilet tissue.”
2. “Use the whole Peri bottle of water to cleanse the perineum.”
3. “Fill the Peri bottle with sterile water warmed to approximately 98° F (37.7° C).”
4. “Flush the perineal area twice a day for 20 minutes.”

Answer 9

2. “Use the whole Peri bottle of water to cleanse the perineum.”

Rational

To properly use a squeeze bottle (often called a Peri bottle) after an episiotomy, the goal is to gently cleanse the perineal area to prevent infection and promote healing.

2. Using the whole Peri bottle of water ensures thorough cleaning and rinsing of the area.

Question 10

The nurse sees that the postpartum patient has a platelet count that is on the high end of the normal range. Based on this observation, which action will the nurse perform?

1. Observe the patient for fatigue, particularly after exertion.
2. Monitor temperature and watch for signs of infection.
3. Encourage the patient to get out of bed and walk around.
4. Watch for signs and symptoms of hemorrhage.

Answer 10

3. Encourage the patient to get out of bed and walk around.

Rational

In the context of postpartum care, a high-end normal platelet count indicates normal clotting ability and does not immediately suggest a risk of hemorrhage. However, it may suggest a risk of thromboembolism, especially if the patient is not moving around enough. Encouraging mobility is important postpartum to reduce this risk.

3. Encouraging the patient to walk around helps prevent blood clots, which is a concern with higher platelet counts.

Question 11

In the postpartum period, the patient has no urge to void, but the nurse notes that the patient’s bladder is distended. What complications are most associated with bladder dis-tention in postpartum patients?

1. Uterine hemorrhage and urinary tract
   infections
2. Rectocele and uterine prolapse
3. Kidney dysfunction and painful sexual intercourse
4. Urinary incontinence and perineal lacerations

Answer 11

1. Uterine hemorrhage and urinary tract
   infections

Rational

In the postpartum period, a distended bladder can interfere with uterine contraction, leading to uterine atony and potential uterine hemorrhage. Additionally, urinary retention and bladder distention can increase the risk of urinary tract infections due to incomplete emptying of the bladder and bacterial growth. These complications are most directly associated with bladder distention in postpartum patients.

Question 12

The postpartum patient complains of a persistent headache. Which action would the nurse perform first?

1. Obtain an order for a mild analgesic, such as acetaminophen.
2. Reassure that pregnancy-induced headaches will abate.
3. Check the blood pressure and compare it to baseline measurements.
4. Check the record for history of epidural or spinal anesthesia.

Answer 12

3. Check the blood pressure and compare it to baseline measurements.

Rational

When a postpartum patient complains of a persistent headache, it is crucial to first rule out any potentially serious conditions such as preeclampsia, which can occur after childbirth. A sudden, severe, or persistent headache can be a symptom of elevated blood pressure, which is a common indicator of preeclampsia. Therefore, the nurse should first check the blood pressure and compare it to baseline measurements to assess for any significant changes that might indicate a hypertensive disorder.

Question 13

The nurse is trying to teach a 15-year-old mother how to swaddle her baby, but the young mother seems more interested in fixing her hair and makeup. She states, “My boyfriend is coming in a little while.” How would the nurse respond?

1. “Let’s focus on the swaddling, then you can show him when he gets here.”
2. “You look very pretty. He will be delighted to see you and the baby.”
3. “Don’t you want to spend some time holding and snuggling your baby?”
4. “Well, you finish with your makeup and I’ll take the baby back to the nursery.”

Answer 13

2. “You look very pretty. He will be delighted to see you and the baby.”

Question 14

The woman’s temperature is slightly elevated
12 hours after delivery of the baby. Which additional assessment would the nurse perform first?

1. Check the appearance and odor of the lochia.
2. Assess skin turgor and condition of mucous membranes.
3. Palpate the fundus for height and firmness.
4. Check a urine specimen for foul odor and cloudiness.

Answer 14

2. Assess skin turgor and condition of mucous membranes.

Question 15

In the first few hours after birth, the neonate who is breastfed has a blood glucose level of 45 mg/dL. The nurse prepares for which intervention?

1. Oral feeding of sterile glucose water
2. Oral feeding of prepared formula
3. Oral feeding of breast milk
4. Administration of intravenous dextrose

Answer 15

3. Oral feeding of breast milk

Rational

In the context of a neonate with a blood glucose level of 45 mg/dL, it’s important to consider that newborns often experience transient lower blood glucose levels shortly after birth. However, maintaining adequate glucose levels is important to prevent hypoglycemia.

Breastfeeding is generally encouraged to maintain glucose levels as it provides the necessary nutrients and energy. Among the options provided:

3. Oral feeding of breast milk is the most natural and beneficial way to help stabilize the neonate’s glucose levels while supporting maternal-infant bonding and providing essential nutrients.