Evolve Chaps 13-14, 16-18

Question 1

As part of the postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding woman who is 1 day postpartum. An expected finding would be:

a. Presence of soft, nontender colostrum.
b. Leakage of milk at let-down
c. Swollen, warm, and tender on palpation.
d. A few blisters and a bruise on each areola.

Answer 1

a.

Breasts are essentially unchanged for the first 2 to 3 days after birth. Colostrum is present and may leak from the nipples.

Question 2

A woman gave birth to a 7-pound, 3-ounce infant boy 2 hours ago. The nurse determines that the woman’s bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate postpartum period, the most serious consequence likely to occur from bladder distention is:

a. Urinary tract infection.
b. Excessive uterine bleeding.
c. A ruptured bladder.
d. Bladder wall atony.

Answer 2

b.

Excessive bleeding can occur immediately after birth if the bladder becomes distended because it pushes the uterus up and to the side and prevents it from contracting firmly.

Question 3

Which statement by a newly delivered woman indicates that she knows what to expect about her menstrual activity after childbirth?

a. “My first menstrual cycle will be lighter than normal and then will get heavier every month thereafter.”
b. “My first menstrual cycle will be heavier than normal, and my period will return to my prepregnant volume within three or four cycles.”
c. “I will not have a menstrual cycle for 6 months after childbirth.”
d. “My first menstrual cycle will be heavier than normal and then will be light for several months after.”

Answer 3

b.

Saying the first menstrual cycle will be heavier than normal and the subsequent three or four cycles will return to prepregnant volume is an accurate statement and indicates her understanding of her expected menstrual activity.

Question 4

Which description of postpartum restoration or healing times is accurate?

a. The cervix shortens, becomes firm, and returns to form within a month postpartum.
b. The vagina gradually returns to prepregnancy size by 6 to 10 weeks after childbirth.
c. Most episiotomies heal within a week.
d. Hemorrhoids usually decrease in size within 2 weeks of childbirth.

Answer 4

b.

The vagina returns to prepregnancy size by 6 to 10 weeks; however, lubrication may take longer to return to prepregnancy level.

Question 5

The breasts of a bottle-feeding woman are engorged. The nurse should tell her to:

a. Wear a snug, supportive bra.
b. Allow warm water to soothe the breasts during a shower.
c. Express milk from breasts occasionally to relieve discomfort.
d. Place absorbent pads with plastic liners into her bra to absorb leakage.

Answer 5

a.

A snug, supportive bra limits milk production and reduces discomfort by supporting the tender breasts and limiting their movement.

Question 6

With regard to afterbirth pains, nurses should be aware that these pains are:

a. Caused by mild, continuous contractions for the duration of the postpartum period.
b. More common in first-time mothers.
c. More noticeable in births in which the uterus was overdistended.
d. Alleviated somewhat when the mother breastfeeds.

Answer 6

c.

A large baby or multiple babies overdistend the uterus and this accounts for afterbirth pains.

Question 7

Postbirth uterine/vaginal discharge, called lochia:

a. Is similar to a light menstrual period for the first 6 to 12 hours.
b. Is usually greater after cesarean births.
c. Will usually decrease with ambulation and breastfeeding.
d. Should smell like normal menstrual flow unless an infection is present.

Answer 7

d.

An offensive odor usually indicates an infection.

Question 8

Although all other joints return to their normal prepregnancy state, those in the parous woman’s feet do not. The new mother may notice a permanent increase in her shoe size.

a. True
b. False

Answer 8

a.

Question 9

Changes in the maternal immune system during the postpartum period account for the profuse diaphoresis that new mothers experience.

a. True
b. False

Answer 9

b.

No significant changes in the maternal immune system occur during the postpartum period.

Question 10

When palpating the fundus of a woman 18 hours after birth, the nurse notes that it is firm, 2 fingerbreadths above the umbilicus, and deviated to the left of midline. The nurse should:

a. Massage the fundus.
b. Administer Methergine, 0.2 mg PO, that has been ordered prn.
c. Assist the woman to empty her bladder Correct
d. Recognize this as an expected finding during the first 24 hours following birth

Answer 10

c.

The findings indicate a full bladder, which pushes the uterus up and to the right or left of midline. The recommended action would be to empty the bladder. If the bladder remains distended, uterine atony could occur, resulting in a profuse flow.

Question 11

Which finding 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 beats/min
d. Pain in left calf with dorsiflexion of left foot Correct

Answer 11

d.

Findings of pain in the left calf with dorsiflexion of the left foot indicate a positive Homan’s sign and are suggestive of thrombophlebitis and should be investigated.

Question 12

The nurse examines a woman 1 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. Correct
c. Call the physician.
d. Administer Methergine, 0.2 mg IM, which has been ordered prn.

Answer 12

b.

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.

Question 13

Perineal care is an important infection control measure. When evaluating a postpartum woman’s perineal care technique, the nurse would recognize the need for further instruction if the woman:

a. Uses soap and warm water to wash the vulva and perineum.
b. Washes from symphysis pubis back to episiotomy.
c. Changes her perineal pad every 2 to 3 hours.
d. Uses the peribottle to rinse upward into her vagina.

Answer 13

d.

The peribottle should be used in a backward direction over the perineum. The flow should never be directed upward into the vagina because debris would be forced upward into the uterus through the still-open cervix.

Question 14

Which measure would be least effective in preventing postpartum hemorrhage?

a. Administer Methergine, 0.2 mg every 6 hours for four doses, as ordered.
b. Encourage the woman to void every 2 hours.
c. Massage the fundus every hour for the first 24 hours following birth.
d. Teach the woman the importance of rest and nutrition to enhance healing.

Answer 14

c.

The fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it to relax.

Question 15

While admitting the pregnant woman, the nurse should be aware that postpartum hospital stays that are becoming shorter are primarily the result of the influence of:

a. Health maintenance organizations (HMOs) and private insurers.
b. Consumer demand.
c. Hospitals.
d. The federal government.

Answer 15

a.

The trend for shortened hospital stays is based largely on efforts to reduce health care costs.

Question 16

Discharge instruction, or teaching the woman what she needs to know to care for herself and her newborn, officially begins:

a. At the time of admission to the nurse’s unit. Correct
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.

Answer 16

a.

Discharge planning, the teaching of maternal and newborn care, begins on the woman’s admission to the unit, continues throughout her stay, and actually never ends as long as she has contact with medical personnel.

Question 17

The _________________________ test is used to detect the amount of fetal blood in the maternal circulation.

Answer 17

Kleihauer-Betke

If more than 15 ml of fetal blood is present in maternal circulation, the dose of Rh immune globulin must be increased.

Question 18

What would be a warning sign of ineffective adaptation to extrauterine life if noted when assessing a 24-hour-old breastfed newborn before discharge?

a. Apical heart rate of 90 beats/min, slightly irregular, when awake and active
b. Acrocyanosis
c. Harlequin color sign
d. Weight loss representing 5% of the newborn’s birth weight

Answer 18

a.

The heart rate of a newborn should range from 120 to 140 beats/min, especially when active. The rate should be regular with sharp, strong sounds.

Question 19

When caring for a newborn, the nurse must be alert for signs of cold stress, including:

a. Decreased activity level.
b. Increased respiratory rate.
c. Hyperglycemia.
d. Shivering.

Answer 19

b.

An increased respiratory rate is a sign of cold stress in the newborn.

Question 20

The nurse helps a breastfeeding mother change the diaper of her 16-hour-old newborn after the first bowel movement. The mother expresses concern because the large amount of thick, sticky stool is very dark green, almost black in color. She asks the nurse if something is wrong. The nurse should respond to this mother’s concern by:

a. Telling the mother not to worry because all breastfed babies have this type of stool.
b. Explaining to the mother that the stool is called meconium and is expected of all newborns for the first few bowel movements.
c. Asking the mother what she ate at her last meal.
d. Suggesting that the mother ask her pediatrician to explain newborn stool patterns to her.

Answer 20

b.

At this early age, this type of stool (meconium) is typical of both bottle-fed and breastfed newborns.

Question 21

When weighing a newborn, the nurse should:

a. Leave its diaper on for comfort.
b. Place a sterile scale paper on the scale for infection control.
c. Keep a hand on the newborn’s abdomen for safety.
d. Weigh the newborn at the same time each day for accuracy.

Answer 21

d.

Weighing a newborn at the same time each day allows for accurate weights.

Question 22

Vitamin K is given to the newborn to:

a. Reduce bilirubin levels.
b. Increase the production of red blood cells.
c. Enhance ability of blood to clot.
d. Stimulate the formation of surfactant.

Answer 22

c.

Newborns have a deficiency of vitamin K until intestinal bacteria that produce vitamin K are formed. Vitamin K is required for the production of certain clotting factors.

Question 23

The nurse notes that, when the newborn is placed on the scale, he immediately abducts and extends his arms and his fingers fan out with the thumb and forefinger forming a “C.” This response is known as a:

a. Tonic neck reflex.
b. Moro reflex.
c. Cremasteric reflex.
d. Babinski reflex.

Answer 23

b.

These actions show the Moro reflex.

Question 24

A newborn male, estimated to be 39 weeks of gestation, would exhibit:

a. Extended posture when at rest.
b. Testes descended into scrotum.
c. Abundant lanugo over his entire body.
d. Ability to move his elbow past his sternum.

Answer 24

b.

A full-term male infant will have both testes in his scrotum and rugae on his scrotum.

Question 25

While examining a newborn, the nurse notes uneven skinfolds on the buttocks and a click sound when performing the Ortolani maneuver. The nurse recognizes these findings as a sign that the newborn probably has:

a. Polydactyly.
b. Clubfoot.
c. Hip dysplasia.
d. Webbing

Answer 25

c.

The Ortolani maneuver is used to detect the presence of hip dysplasia.

Question 26

A patient feels too warm and asks for a fan in her room for her comfort. The nurse enters the room to assess the mother and her infant and finds the infant unwrapped in his crib with the fan blowing over him on “high.” The nurse instructs the mother that the fan should not be directed toward the newborn and the newborn should be wrapped in a blanket. The mother asks why. The nurse’s best response is:

a. “Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him.”
b. “Your baby may lose heat by conduction, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him.”
c. “Your baby may lose heat by evaporation, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him.”
d. “Your baby will get cold stressed easily and needs to be bundled up at all times.”

Answer 26

a.

Saying the baby will lose heat by convection is an accurate statement.

Question 27

All of these statements describe the first phase of the transition period except:

a. It lasts no longer than 30 minutes.
b. It is marked by spontaneous tremors, crying, and head movements.
c. It includes the passage of meconium.
d. It may involve the infant suddenly sleeping briefly.

Answer 27

d.

The first phase is an active phase in which the baby is alert. Decreased activity and sleep mark the second phase.

Question 28

The shivering mechanism of heat production is rarely functioning in the newborn. Nonshivering _________________________ is accomplished primarily by metabolism of brown fat, which is unique to the newborn, and by increased metabolic activity in the brain, heart, and liver.

Answer 28

thermogenesis

Hypothermia from excessive heat loss is a common and dangerous problem in neonates. The newborn infant’s ability to produce heat (thermogenesis) often approaches that of the adult; however, the tendency toward rapid heat loss in a cold environment is increased in the newborn and poses a hazard.

Question 29

At 1 minute following birth, a newborn exhibited the following: heart rate of 155; loud, vigorous crying with active movement of all extremities; sneezing when nose was stimulated with a catheter; hands and feet bluish and cool to the touch. The Apgar score of this newborn should be recorded as:

a. 5.
b. 7.
c. 9.
d. 10.

Answer 29

c.

The newborn receives 2 points each for a heart rate over 100 beats/min, a vigorous cry, active movement, and sneezing as a response to nasal stimulation. The newborn receives 1 point for color because he exhibits acrocyanosis. The point total is 9.

Question 30

The nurse must administer erythromycin ophthalmic ointment to a newborn after birth. The nurse should:

a. Instill within 15 minutes of birth for maximum effectiveness.
b. Cleanse eyes from inner to outer canthus before administration.
c. Apply directly over the cornea.
d. Flush eyes 10 minutes after instillation to reduce irritation.

Answer 30

b.

The newborn’s eyes should be cleansed from the inner to the outer canthus before the administration of erythromycin ointment.

Question 31

Newborns are at high risk for injury if appropriate safety precautions are not implemented. Parents should be taught to:

a. Place newborn on abdomen (prone) after feeding and for sleep.
b. Avoid use of pacifiers.
c. Use a rear-facing car seat until the infant weighs at least 20 lb.
d. Use a crib with side-rail slats that are no more than 3 inches apart.

Answer 31

c.

The APA recommends using a rear-facing car seat until a baby weighs 20 lb.

Question 32

Following circumcision of a newborn, the nurse provides instructions to his parents regarding postcircumcision care. The nurse should tell the parents to:

a. Apply topical anesthetics with each diaper change.
b. Expect a yellowish exudate to cover the glans after the first 24 hours.
c. Change the diaper every 2 hours and cleanse the site with soap and water or baby wipes.
d. Apply constant pressure to the site if bleeding occurs and call the physician.

Answer 32

b.

Parents should be taught that a yellow exudate will develop over the glans and should not be removed.

Question 33

When placing a newborn under a radiant heat warmer to stabilize temperature after birth, the nurse should:

a. Place the thermistor probe on left side of the chest.
b. Cover probe with a nonreflective material.
c. Recheck temperature by periodically taking a rectal temperature.
d. Prewarm the radiant heat warmer and place the undressed newborn under it.

Answer 33

d.

The radiant warmer should be prewarmed so the infant does not experience more cold stress.

Question 34

With regard to umbilical cord care, nurses should be aware that:

a. The stump can easily become infected.
b. A nurse noting bleeding from the vessels of the cord should immediately call for assistance.
c. The cord clamp is removed at cord separation.
d. The average cord separation time is 5 to 7 days.

Answer 34

a.

The cord stump is an excellent medium for bacterial growth.

Question 35

During the complete physical examination 24 hours after birth:

a. The parents are excused from the room to reduce their normal anxiety.
b. The nurse can gauge the neonate’s maturity level by assessing its general appearance.
c. Once often neglected, blood pressure is now routinely checked.
d. When the nurse listens to the heart, the S1 and S2 sounds can be heard; the first sound is somewhat higher in pitch and sharper than the second.

Answer 35

b.

The nurse is able to gauge maturity level by assessing appearance. The nurse will be looking at skin color, alertness, cry, head size, and other features.

Question 36

With regard to laboratory tests and diagnostic tests performed in the hospital after birth, nurses should be aware that:

a. All states test for phenylketonuria (PKU), hypothyroidism, cystic fibrosis, and sickle cell diseases.
b. Federal law prohibits newborn genetic testing without parental consent.
c. If genetic screening is done before the infant is 24 hours old, it should be repeated at age 1 to 2 weeks.
d. Hearing screening is now mandated by federal law.

Answer 36

c.

If done very early, genetic screening should be repeated.

Question 37

The nurse is performing a blood glucose test every 4 hours on an infant born to a diabetic mother. This is to assess the infant’s risk of hypoglycemia. The nurse becomes concerned if the infant’s blood glucose concentration falls below ____________________ mg/dl.

Answer 37

36

If the newborn has a blood glucose level below 36 mg/dl, intervention such as breatfeeding or bottle-feeding should be instituted. If levels remain low after this intervention, an intravenous infusion with dextrose may be warranted.

Question 38

The birth weight of a breastfed newborn was 8 pounds, 4 ounces. On the third day the newborn’s weight was 7 pounds, 12 ounces. On the basis of this finding, the nurse should:

a. Encourage the mother to continue breastfeeding because it is effective in meeting the newborn’s nutrient and fluid needs.
b. Suggest that the mother switch to bottle-feeding because the breastfeeding is ineffective in meeting the newborn’s needs for fluid and nutrients.
c. Notify the physician because the newborn is being poorly nourished.
d. Refer the mother to a lactation consultant to improve her breastfeeding technique.

Answer 38

a.

Weight loss of 8 ounces falls within the 5% to 10% expected weight loss from birth weight during the first few days of life, which for this newborn would be 6.6 to 13.2 ounces. Breastfeeding is effective at this time.

Question 39

Which action of a breastfeeding mother indicates the need for further instruction?

a. Holds breast with four fingers along bottom and thumb at top
b. Leans forward to bring breast toward the baby
c. Stimulates the rooting reflex and then inserts nipple and areola into newborn’s open mouth
d. Puts her finger into newborn’s mouth before removing breast

Answer 39

b.

To maintain a comfortable, relaxed position, the mother should bring the baby to the breast, not the breast to the baby. The mother would need further demonstration and teaching to correct the ineffective action.

Question 40

The nurse taught new parents the guidelines to follow regarding the bottle feeding of their newborn. They will be using formula from a can of concentrate. The parents would demonstrate an understanding of the nurse’s instructions if they:

a. Wash the top of the can and the can opener with soap and water before opening the can.
b. Adjust the amount of water added according to weight gain pattern of the newborn.
c. Add some honey to sweeten the formula and make it more appealing to a fussy newborn.
d. Warm formula in a microwave oven for a couple of minutes prior to feeding.

Answer 40

a.

Washing the top of the can and the can opener with soap and water before opening the can of formula is a good habit for parents to get into to prevent contamination of the formula.

Question 41

Benefits to the mother associated with breastfeeding include all except it:

a. Decreases risk of breast cancer.
b. Is an effective method of birth control.
c. Increases bone density.
d. May enhance postpartum weight loss.

Answer 41

b.

Breastfeeding delays the return of fertility, but it is NOT an effective birth control method.

Question 42

With regard to the special qualities of human breast milk, nurses should be aware that:

a. Frequent feedings during predictable growth spurts stimulate increased milk production.
b. The milk of preterm mothers is the same as the milk of mothers who gave birth at term.
c. The milk at the beginning of the feeding is the same as the milk at the end of the feeding.
d. Colostrum is an early, less concentrated, less rich version of mature milk.

Answer 42

a.

Growth spurts (at 10 days, 3 weeks, 6 weeks, 3 months) usually last 24 to 48 hours, after which infants resume normal feeding and milk production returns to previous production level.

Question 43

Nurses should be able to tell breastfeeding mothers that all of the following are signs that the infant has latched on correctly to her breast except:

a. She feels a firm tugging sensation on her nipples but not pinching or pain.
b. The baby sucks with cheeks rounded, not dimpled.
c. The baby’s jaw glides smoothly with sucking.
d. She hears a clicking or smacking sound when the infant feeds.

Answer 43

d.

The clicking or smacking sound may indicate that the baby is having difficulty keeping the tongue out over the lower gum ridge. The mother should hope to hear the sound of swallowing.

Question 44

With regard to basic care of the breastfeeding mother, nurses should be able to advise her that she:

a. Will need an extra 1000 calories a day to maintain energy and produce milk.
b. Can go back to prepregnancy consumption patterns of any drinks as long as she gets enough calcium.
c. Should avoid trying to lose large amounts of weight.
d. Must avoid exercising because it is too fatiguing.

Answer 44

c.

Large weight loss would release fat-stored contaminants into her breast milk. It would also likely involve eating too little and/or exercising too much.

Question 45

Examples of appropriate techniques to wake a sleepy infant for breastfeeding include (choose all that apply):

a. Unwrapping the infant.
b. Changing the diaper.
c. Talking to the infant.
d. Slapping the infant’s hands and feet.
e. Applying a cold towel to the infant’s abdomen.

Answer 45

a,b,c

Unwrapping the infant is an appropriate technique to use when trying to wake a sleepy infant.
Changing the diaper is an appropriate technique to use when trying to wake a sleepy infant.
Talking to the infant is an appropriate technique to use when trying to wake a sleepy infant.