96 terms


A mother of a term neonate asks what the thick, white, cheesy coating is on his skin. Which correctly describes this finding?
1. Lanugo
2. Milia
3. Nevus flammeus
4. Vernix
A client has just given birth at 42 weeks' gestation. When assessing the neonate, which physical finding is expected?
1. A sleepy, lethargic baby
2. Lanugo covering the body
3. Desquamation of the epidermis
4. Vernix caseosa covering the body
3. Postdate fetuses lose the vernix caseosa, and the epidermis may become desquamated. These neonates are usually very alert. Lanugo is missing in the postdate neonate.
The father of a newly delivered infant expresses concern about the white, cheesy material seen on a baby's skin. The nurse explains that this is a normal finding and is called:
a. Lanugo
b. Vernix caseosa
c. Cutis marmorata
d. Mongolian spots
Vernix caseosa protects the skin of the fetus from moisture before delivery. As a rule, it does not need to be washed off and is left to be absorbed. Lanugo is the fine, downy hair usually found on the shoulders. Cutis marmorata is a lacelike red or blue pattern on the skin surface, and mongolian spots are dark blue or slate gray discolorations usually found on the lumbosacral area.
The infant of a woman who has diabetes mellitus is admitted to the newborn nursery. It is especially important for the nurse to assess for:
a. Anemia
b. Respiratory distress
c. Hyperglycemia
d. Adrenal insufficiency
The infant of a woman with diabetes has an increased risk for respiratory distress syndrome (RDS) because high levels of insulin appear to interfere with the production of lung surfactant. Other possible complications include polycythemia, hypoglycemia, and birth trauma (as a result of macrosomia).
A baby was born 2 hours ago at 37 weeks' gestation weighing 4139 g (9 lbs, 2 oz). The newborn appears chubby with a flushed complexion and is very shaky. The tremors are most likely the result of:
a. Birth injury
b. Seizures
c. Hypoglycemia
d. Hypocalcemia
After birth, maternal glucose is no longer available to the newborn. However, the newborn's pancreas continues to produce an increased amount of insulin, resulting in hypoglycemia.
The nurse caring for a 4479 g (9 lbs, 14 oz) infant of a diabetic mother who was born by cesarean delivery 3 hours ago observes a respiratory rate of 90 breaths/minute, nasal flaring, and expiratory grunting. She reports the findings and recognizes that the newborn most likely has:
a. Hypothyroidism
b. Hypoglycemia
c. Transient tachypnea of the newborn
d. Neonatal sepsis
Large infants of diabetic mothers and those born by cesarean delivery are at risk for transient tachypnea of the newborn (TTN), a self-limiting disorder caused by a slight lack of surfactant and/or a delayed reabsorption of fetal lung fluid.
Neonates of mothers with diabetes are at risk for which complication following birth?
1. Atelectasis
2. Microcephaly
3. Pneumothorax
4. Macrosomia
4. Neonates of mothers with diabetes are at increased risk for macrosomia (excessive fetal growth) as a result of the combination of the increased supply of maternal glucose and an increase in fetal insulin.
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:
1. "You infant needs vitamin K to develop immunity."
2. "The vitamin K will protect your infant from being jaundiced."
3. "Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding."
4. "Newborn infants have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel."
3. Vitamin K is necessary for the body to synthesize coagulation factors. Vitamin K is administered to the newborn infant to prevent abnormal bleeding. Newborn infants are vitamin K deficient because the bowel does not have the bacteria necessary for synthesizing fat-soluble vitamin K. The infant's bowel does not have support the production of vitamin K until bacteria adequately colonizes it by food ingestion.
Vitamin K is prescribed for a neonate. A nurse prepares to administer the medication in which muscle site?
1. Deltoid
2. Triceps
3. Vastus lateralis
4. Biceps
When performing nursing care for a neonate after a birth, which intervention has the highest nursing priority?
1. Obtain a dextrostix
2. Give the initial bath
3. Give the vitamin K injection
4. Cover the neonates head with a cap
4. 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.
When newborns have been on formula for 36-48 hours, they should have a:
1. Screening for PKU
2. Vitamin K injection
3. Test for necrotizing enterocolitis
4. Heel stick for blood glucose level
1. 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 blood stream and brain; early detection can determine if the liver enzyme is absent.
A neonate has been diagnosed with caput succedaneum. Which statement is correct about this condition?
1. It usually resolves in 3-6 weeks
2. It doesn't cross the cranial suture line
3. It's a collection of blood between the skull and the periosteum
4. It involves swelling of tissue over the presenting part of the presenting head
4. 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.
If the nurse notes a soft swollen area on the newborn infant's scalp that extends over the suture lines, she should:
a. Apply an ice pack and reassess every hour.
b. Document caput succedaneum; no action is necessary.
c. Notify the health care provider that the infant may have a cephalhematoma.
d. Explain to the mother that the skull has been molded to pass through the birth canal.
Caput succedaneum is a localized swelling of soft tissue of the scalp caused by pressure on the head during labor. It resolves with no special treatment. A cephalhematoma, a collection of blood between the periosteum and a bone of the skull, does not cross suture lines.
A cephalhematoma is an:
a. Accumulation of blood between the skin and the periosteum
b. Edematous molding of the skull resulting from pressure at birth
c. Accumulation of blood between the periosteum and a bone of the fetal skull
d. Accumulation of cerebrospinal fluid between the dura mater and a skull bone
A cephalhematoma is an accumulation of blood between the periosteum and a bone of the infant's skull, usually as a result of a prolonged or difficult labor. It may be unilateral or bilateral and does not cross the suture line. Resolution may take up to 3 weeks.
The discharge teaching plan for the postpartum woman includes information about expected vaginal discharge. Which statement should be included?
a. Lochia normally has an offensive odor.
b. Bright-red bleeding, called lochia rubra, will continue for 10 to 14 days.
c. Small blood clots are normal in lochia rubra, lochia serosa, and lochia alba.
d. Notify your health care provider if lochia does not become lighter in color by the fourth postpartum day.
Normally, lochia is red for the first 1 to 3 days, lightens and turns a brownish color from days 4 to 10, and is yellow or white by the tenth day. The odor should not be unpleasant. Small blood clots are normal in the first few days only.
What is the normal sequence of postpartum vaginal discharge?
a. Lochia serosa, lochia alba, lochia rubra
b. Lochia rubra, lochia serosa, lochia alba
c. Lochia alba, lochia rubra, lochia serosa
d. Lochia serosa, lochia rubra, lochia alba
As lochia changes from red to brown to yellow or white, it is called, respectively, lochia rubra, lochia serosa, and lochia alba.
The nurse is caring for a woman who is gravida 2, para 1 on her first postpartum day. The assessment reveals: temperature 38° C (100° F), pulse 60 beats/minute, blood pressure 118/80 mm Hg, fundus firm at the level of umbilicus and displaced slightly to right, last void 6 hours earlier, moderate amount of lochia rubra, and perineum slightly edematous with episiotomy edges well approximated. The first nursing action should be to:
a. Notify the nurse-midwife of her temperature.
b. Apply an ice pack to her perineum.
c. Assist her to the bathroom to void.
d. Chart the assessment findings as normal.
Uterine displacement is usually associated with bladder distention. After the nurse takes her to the bathroom to void, the uterus should shift to a midline position. The other findings are normal.
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:
1. Normal
2. Indicates the presence of infection
3. Indicates the need for increasing oral fluids
4. Indicates the need for increasing ambulation
2. 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.
When performing a PP assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which of the following nursing actions is most appropriate?
1. Document the findings
2. Notify the physician
3. Reassess the client in 2 hours
4. Encourage increased intake of fluids.
2. Normally, one may find a few small clots in the first 1 to 2 days after birth from pooling of blood in the vajayjay. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the most appropriate action is to notify the physician.
A nurse in a PP unit is instructing a mother regarding lochia and the amount of expected lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never exceed the need for:
1. One peripad per day
2. Two peripads per day
3. Three peripads per day
4. Eight peripads per day
4. The normal amount of lochia may vary with the individual but should never exceed 4 to 8 peripads per day. The average number of peripads is 6 per day.
On which of the postpartum days can the client expect lochia serosa?
1. Days 3 and 4 PP
2. Days 3 to 10 PP
3. Days 10-14 PP
4. Days 14 to 42 PP
2. 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.
Which type of lochia should the nurse expect to find in a client 2 days PP?
1. Foul-smelling
2. Lochia serosa
3. Lochia alba
4. Lochia rubra
Patient teaching to prevent mastitis should include which point?
a. Use proper breastfeeding techniques.
b. Wash nipples and breasts daily with mild soap and water.
c. Wear a supportive bra 24 hours a day.
d. Use a nipple shield for the first few days of breastfeeding.
Poor breastfeeding techniques can contribute to breast engorgement, milk stasis, and nipple trauma, increasing the risk for mastitis. Nipples and breasts should be washed with water only. A supportive bra may provide comfort but will not prevent mastitis. Use of a nipple shield for the first few days of breastfeeding is not generally recommended because it is more difficult for the infant to completely empty the breasts.
Three weeks following delivery, the new mother develops mastitis. Which statement by the nurse is most appropriate?
a. "It's sad that you won't be able to breastfeed any longer."
b. "Continuing to breastfeed frequently will aid in pain relief."
c. "You should pump your breasts until the infection is cleared."
d. "Only allow your baby to nurse for five minutes on each breast."
Emptying the breast decreases engorgement and provides pain relief. It is not necessary to stop breastfeeding due to mastitis. A baby with vigorous sucking can empty the breast better than a pump or manual expression. The infant should be allowed to fully empty the breast. Feeding can be done every 1 1/2 to 2 hours to ensure comfort and prevent milk stasis.
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?
1. "I need to take antibiotics, and I should begin to feel better in 24-48 hours."
2. "I can use analgesics to assist in alleviating some of the discomfort."
3. "I need to wear a supportive bra to relieve the discomfort."
4. "I need to stop breastfeeding until this condition resolves."
4. In most cases, the mother can continue to breast feed 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.
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.
1. Take the prescribed antibiotics until the soreness subsides.
2. Wear supportive bra
3. Avoid decompression of the breasts by breastfeeding or breast pump
4. Rest during the acute phase
5. Continue to breastfeed if the breasts are not too sore.
2, 4, and 5. 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.
The reduction in the size of the uterus immediately after birth is referred to as:
a. Exfoliation
b. Involution
c. Puerperium
d. Regeneration
Involution refers to the changes that occur in a woman's body after birth to restore the organs to the pre-pregnant state. This includes the reduction in uterine size and weight.
The nurse is assessing a woman on her second postpartum day. Her fundus is palpated midline, 1 cm below the umbilicus. Her bladder is not palpable. The correct conclusion based on these findings is that her:
a. Fundus is descending normally.
b. Bladder is positioned behind the uterus.
c. Bladder is displacing the uterus upward.
d. Uterus is not contracting as well as it should.
At delivery, the fundus is above the umbilicus. Each day, it descends approximately 1 cm until it returns to the normal position in the pelvis. On the first postpartum day, you would expect the fundus to be near or just below the umbilicus. If the bladder were distended, it would displace the uterus upward and away from the midline.
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?
1. Massage the fundus until it is firm
2. Elevate the mothers legs
3. Push on the uterus to assist in expressing clots
4. Encourage the mother to void
1. 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.
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?
1. Retained placental fragments
2. Urinary tract infection
3. Cervical laceration
4. Uterine atony
3. 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.
The nurse is caring for a patient with endometritis. When the patient asks where her infection is located, the nurse explains that the infection is located in which area(s)? (Select all that apply.)
a. Endometrial lining
b. Decidua
c. Lymph nodes
d. Myometrium
e. Peritoneum
A, B, D
Endometritis is an infection of the endometrial lining, the deciduas, and the myometrium.
Which assessment suggests that a woman has endometritis?
a. Large, tender uterus; bradycardia; fever
b. Enlarged, boggy uterus; moderate, bright-red lochia
c. Fever, uterine tenderness, foul-smelling lochia
d. Firm uterus, small amount of pink lochia, fleshy odor
Endometritis is characterized by fever (and tachycardia), malaise, uterine enlargement and tenderness, and foul-smelling lochia.
Infection spread through the uterine wall to the broad ligaments or entire pelvis is known as:
a. Endometritis
b. Parametritis
c. Peritonitis
d. Metritis
Parametritis is an infection that has spread through the uterine wall to the broad ligaments or entire pelvis.
Which statement describes one of Rubin's phases of maternal adaptation?
a. The first phase is taking in, when the woman assumes her new maternal role.
b. The second phase is taking hold, when the woman asserts her independence.
c. The third phase is letting go, when the mother accepts dependence on others.
d. The fourth phase is attainment, when the mother has learned mothering behaviors.
Rubin's phases are taking in, taking hold, and letting go. Taking in is when the woman is passive and dependent; taking hold is when she asserts her independence; and letting go is when she assumes her new maternal role.
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?
1. Depression phase
2. Letting-go phase
3. Taking-hold phase
4. Taking-in phase
4. 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.
Which of the following behaviors characterizes the PP mother in the taking in phase?
1. Passive and dependant
2. Striving for independence and autonomy
3. Curious and interested in care of the baby
4. Exhibiting maximum readiness for new learning
1. During the taking in phase, which usually lasts 1-3 days, the mother is passive and dependent and expresses her own needs rather than the neonate's needs. The taking hold phase usually lasts from days 3-10 PP. During this stage, the mother strives for independence and autonomy; she also becomes curious and interested in the care of the baby and is most ready to learn.
Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just wants to sleep. The nurse should:
1. Tell the woman she can rest after she feeds her baby
2. Recognize this as a behavior of the taking-hold stage
3. Record the behavior as ineffective maternal-newborn attachment
4. Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time
4. Response 1 does not take into consideration the need for the new mother to be nurtured and have her needs met during the taking-in stage. The behavior described is typical of this stage and not a reflection of ineffective attachment unless the behavior persists. Mothers need to reestablish their own well-being in order to effectively care for their baby.
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:
1. Foster an active role in the baby's care
2. Provide time for the mother to reflect on the events of and her behavior during childbirth
3. 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
4. Promote maternal independence by encouraging her to meet her own hygiene and comfort needs
2. 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.
During the 3rd PP day, which of the following observations about the client would the nurse be most likely to make?
1. The client appears interested in learning about neonatal care
2. The client talks a lot about her birth experience
3. The client sleeps whenever the neonate isn't present
4. The client requests help in choosing a name for the neonate.
1. 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.
The three most common causes of postpartum hemorrhage are:
a. Uterine atony, thrombocytopenia, and hematoma
b. Uterine atony, lacerations, and retained placenta
c. Lacerations, hematoma, and disseminated intravascular coagulation
d. Retained placenta, uterine atony, and lacerations
The most common causes of early postpartum hemorrhage are uterine atony and lacerations. During the later postpartum period, the most common causes are retained placenta fragments or organized clots.
The nursing care priority in the immediate postpartum period is to:
a. Prevent hemorrhage.
b. Promote the process of involution.
c. Prevent circulatory problems.
d. Foster mother-infant bonding.
Severe bleeding caused by uterine atony is life threatening. It can usually be controlled by maintaining a firm uterus.
During the assessment of a woman in the immediate postpartum period, which finding would alert the nurse to uterine atony?
a. Fundus below the umbilicus
b. Absence of lochia
c. Boggy uterine fundus
d. Severe abdominal pain
A well-contracted uterus feels firm and controls bleeding by clamping down on blood vessels. On the other hand, when the uterus is not contracted, it feels soft or boggy and is prone to bleeding.
The assessment of a newly delivered woman reveals a boggy uterus. The nurse's first intervention should be to:
a. Express clots that have accumulated in the uterus.
b. Contact the physician for an order for oxytocin.
c. Catheterize her to empty the bladder.
d. Massage the uterus until firm.
Massage should be done first. If the uterus does not contract, other measures must be used. Clots should not be expressed until the uterus is firmly contracted.
A postpartum patient complains of perineal pain. Her uterus is firm, and she has minimal vaginal bleeding. She states that she feels like she needs to urinate and have a bowel movement but has been unable to do either. The nurse suspects that the patient most likely has:
a. A hematoma
b. Subinvolution
c. A postpartum infection
d. Disseminated intravascular coagulation
These are classic signs and symptoms of hematoma. A hematoma is a collection of blood within the tissues that may result from injury to blood vessels in the perineum or vagina. Perineal pain, rather than noticeable bleeding, is a distinguishing characteristic of a hematoma, and the uterus remains firm. Pressure on the urethra may cause difficulty voiding, and pressure on the rectum may feel like the need to have a bowel movement.
The most serious complication of thromboembolism is:
a. Gangrene
b. Hemorrhage
c. Varicose veins
d. Pulmonary embolism
An embolus is a clot that is moving through the circulatory system with the blood flow. An embolus may be delivered to the lungs, where it obstructs circulation and can cause sudden death.
During care of a postpartum patient, assessment data include the absence of heat, tenderness, or edema in the legs. The patient reports no pain when the nurse dorsiflexes her foot. The best interpretation of these data is that the patient:
a. Has thrombophlebitis
b. Has no signs of deep vein thrombosis
c. Does not have thrombophlebitis
d. Has thrombophlebitis but not thromboembolism
This patient has no signs of thrombophlebitis. However, sometimes there are no signs or symptoms, so the nurse cannot be positive there is no inflammation or clot formation.
A PP client is being treated for DVT. The nurse understands that the client's response to treatment will be evaluated by regularly assessing the client for:
1. Dysuria, ecchymosis, and vertigo
2. Epistaxis, hematuria, and dysuria
3. Hematuria, ecchymosis, and epistaxis
4. Hematuria, ecchymosis, and vertigo
3. The treatment for DVT is anticoagulant therapy. The nurse assesses for bleeding, which is an adverse effect of anticoagulants. This includes hematuria, ecchymosis, and epistaxis. Dysuria and vertigo are not associated specifically with bleeding.
A nurse is caring for a PP client with a diagnosis of DVT who is receiving a continuous intravenous infusion of heparin sodium. Which of the following laboratory results will the nurse specifically review to determine if an effective and appropriate dose of the heparin is being delivered?
1. Prothrombin time
2. Internationalized normalized ratio
3. Activated partial thromboplastin time
4. Platelet count
3. Anticoagulation therapy may be used to prevent the extension of thrombus by delaying the clotting time of the blood. Activated partial thromboplastin time should be monitored, and a heparin dose should be adjusted to maintain a therapeutic level of 1.5 to 2.5 times the control. The prothrombin time and the INR are used to monitor coagulation time when warfarin (Coumadin) is used.
Which of the following findings would be a source of concern if noted during the assessment of a woman who is 12 hours postpartum?
1. Postural hypotension
2. Temperature of 100.4°F
3. Bradycardia — pulse rate of 55 BPM
4. Pain in left calf with dorsiflexion of left foot
4. 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.
During a postpartum assessment, the nurse detects a positive Homans' sign. A positive Homans' sign is elicited when the:
a. Woman stands and feels pain in her foot
b. Knee is slightly flexed, the foot is dorsiflexed, and pain is felt in her calf
c. Knee is held flat, the foot rotated, and pain is felt in her calf
d. Knee is flexed, the foot extended, and pain is felt in her calf
By passive dorsiflexion of the feet, the nurse determines whether there is pain in the calf (a positive Homans' sign). Venous stasis, especially during late pregnancy, contributes to the risk of formation of blood clots in the lower extremities. A positive Homans' sign may be an early indicator of venous thrombosis and should be reported.
Immediately following delivery, a woman's weight decreases rapidly due to which factor(s)? (Select all that apply.)
a. Removal of the fetus
b. Removal of the placenta
c. Expressing of breast milk
d. Diaphoresis
e. Diarrhea
f. Loss of amniotic fluid
A, B, D, F
Immediately after delivery, a woman's weight decreases rapidly due to the removal of the fetus, placenta, and amniotic fluid. Diaphoresis and diuresis also contribute to weight loss immediately after birth.
In a neutral thermal environment, the newborn infant's axillary temperature should remain:
a. At least at 35.5° C (96.0° F)
b. Between 36.5° and 37.5° C (97.7° and 99.5° F)
c. At 37.0° C (98.6° F)
d. Above 36.6° C (98° F)
An axillary temperature between 36.5° and 37.5° C (97.7° and 99.5° F) will minimize heat loss from the skin. A temperature above or below this range can stress the newborn.
What complication should be suspected in the patient who has experienced abruptio placentae, hydatidiform mole, or a retained dead fetus?
a. Pregnancy-induced hypertension
b. Septic shock
c. Disseminated intravascular coagulation
d. Hyperemesis gravidarum
Disseminated intravascular coagulation (DIC) is a coagulation defect that prevents blood from clotting. It can occur with abruptio placentae, hydatidiform mole, pregnancy-induced hypertension, hemorrhagic shock, septic shock, and retained dead fetus.
A young mother who is breastfeeding her infant says, "My friend told me I can't get pregnant again while I am breastfeeding." How should the nurse reply?
a. "That is one advantage of breastfeeding."
b. "You can't get pregnant until your menstrual periods begin."
c. "Actually, breastfeeding increases your chance of pregnancy."
d. "It is possible to become pregnant while breastfeeding."
It is possible to ovulate and become pregnant before menstrual periods are reestablished, whether the woman is breastfeeding or not.
On her second postpartum day, a woman complains of cramping abdominal pains. What should the nurse tell her about these pains?
a. These pains are normal and persist for about 6 weeks.
b. These contractions are usually relieved by breastfeeding.
c. You are having uterine contractions that prevent bleeding.
d. If you have been constipated, you may need a laxative.
Cramping abdominal pains, often called "afterpains," reflect contraction of uterine muscle fibers to prevent excessive blood loss. They are related to the release of oxytocin and increase during breastfeeding. The pain usually lasts 2 to 3 days only.
The maternal hormone that causes the milk ejection reflex is:
a. Estrogen
b. Oxytocin
c. Prolactin
d. Progesterone
Infant suckling causes the posterior pituitary gland to secrete oxytocin, producing the let-down, or milk ejection, reflex, causing the milk to be delivered from the alveoli (milk-producing sacs) to the nipple.
The nurse is teaching a new mother how to prepare for breastfeeding. Which of the following is the most important point to include regarding prevention of breast and infant infection?
a. Hand hygiene
b. Proper cleaning of bottles
c. Use of breast cream
d. Proper positioning
Carefully washing the hands and nipples with plain warm water is the single most important way to prevent infection in infants and maternal breasts.
Patient teaching for the woman who is breastfeeding for the first time should include that:
a. The baby will need to be fed every 4 to 6 hours.
b. Crying is the first sign of hunger in newborn infants.
c. She should allow the baby to suckle no more than 10 minutes at each breast.
d. If the baby sleeps after feeding and gains weight, the milk intake is adequate.
Indications that the infant is getting enough milk are sleeping after feeding, steady weight gain, audible swallowing during nursing, and at least six wet diapers a day. Breastfed babies usually nurse every 2 to 3 hours. Crying is often a late sign of hunger; the mother will notice earlier behaviors such as rooting and hand-to-mouth movements that suggest hunger. Fifteen minutes at each breast is generally recommended.
Advantages of breastfeeding over bottle feeding include:
a. More freedom for the mother
b. Infant eats less often
c. Breast milk is least allergenic for the infant
d. Breast milk provides more protein than formula
The infant is least likely to be allergic to breast milk. However, breastfeeding is more restrictive for the mother, and the infant eats more often. Breast milk has less protein than formula, not more.
The nurse is helping a woman ambulate who is 12 hours post-delivery by cesarean birth. The patient seems reluctant to walk and wants to stay in bed. The nurse informs the woman that early and frequent ambulation is necessary to:
a. Reduce the risk of thromboembolism.
b. Decrease muscle weakness.
c. Increase appetite.
d. Reduce the risk of mastitis.
Early and frequent ambulation is essential to reduce the risk of thromboembolism, one of the leading causes of maternal death.
What should the nurse tell the postpartum patient who does not wish to breastfeed about breast engorgement?
a. Breast engorgement is caused by the accumulation of milk.
b. Swelling and tenderness are normal, but warmth indicates mastitis.
c. A supportive bra, ice packs, and mild analgesics relieve discomfort.
d. Pump the breasts twice daily to reduce engorgement and pain.
Engorgement, which is caused by vasocongestion, usually resolves within a few days. Meanwhile, a supportive bra, ice packs, and mild analgesics help relieve discomfort. Stimulation of the breast such as pumping the milk will cause additional milk production
Which statement best describes postpartum blues?
a. Chronic depression with inability to care for the new baby
b. Transient, self-limiting depression accompanied by tearfulness
c. Difficulty sleeping during the first 3 days postpartum
d. Prolonged depression during the first 6 weeks after delivery
Postpartum blues is a term used to describe a relatively brief period of depression in the postpartum period. It is probably related to hormonal changes and psychological adjustments.
During the postpartum period, the woman should be instructed to report immediately which danger sign to her health care provider?
a. Vaginal discharge persisting over 1 week
b. Leaking of breast milk between feedings
c. Localized pain in the calf or leg
d. Tiring more easily than usual
Localized pain in the calf or leg may indicate thrombophlebitis. The other options are not abnormal.
When conducting a postpartum assessment, the nurse uses the BUBBLE-HE mnemonic. Which of the following are components of the assessment? (Select all that apply.)
a. Breasts
b. Lochia
c. Episiotomy
d. Extremities
e. Bowel
f. Uterus
A, B, C, E, F
Breasts, uterus, bladder, bowel, lochia, episiotomy, Homans' sign, emotions;
use of a memory device such as BUBBLE-HE enables the nurse to perform a systematic, thorough postpartum assessment. In addition to these specific assessments, vital signs, pain, hydration status, ambulation, and parenting should be included.
A full-term, 3175-g (7-lbs) newborn is admitted to the nursery with a temperature of 35.4° C (96° F). The most likely reason for the low body temperature is:
a. An excessively cold delivery room
b. Exhaustion from the birth process
c. Evaporation from wet skin surface at birth
d. A decreased metabolic rate
The most likely explanation for the low temperature is heat loss by evaporation, which occurs when wet surfaces are exposed to air.
The nurse recognizes that cold stress in the newborn can lead to:
a. Acrocyanosis
b. Hyperglycemia
c. Acidosis
d. Atelectasis
With cold stress, metabolism of brown fat releases fatty acids, which can lead to metabolic acidosis. If excess glucose is metabolized in an attempt to maintain body temperature, the infant may become hypoglycemic. Acrocyanosis is normal.
Which physiologic mechanism does the newborn use to maintain body temperature?
a. Shivering
b. Metabolism of brown fat
c. Production of fatty acids
d. Decreased glucose metabolism
The metabolism of brown fat helps the newborn maintain heat around vital organs. Newborns cannot shiver like adults. The production of fatty acids occurs, but it is not adaptive because it can cause metabolic acidosis. Glucose metabolism increases when the newborn is chilled.
The assessment of a newborn at 1 hour of age reveals the following: temperature 36.0° C (96.7° F), heart rate 158 beats/minute, respiratory rate 55 breaths/minute, color pink with acrocyanosis. Based on these clinical findings, the nurse should conclude that:
a. The infant is in respiratory distress.
b. Measures to warm the infant should be taken.
c. The infant is showing signs of cold stress.
d. No nursing interventions are necessary.
The temperature is low, and measures should be instituted to warm the infant to prevent cold stress. The heart and respiratory rates are within normal ranges.
A newborn is placed under a radiant warmer. The nurse understands that thermoregulation presents a problem for newborns because:
a. Their normal flexed posture favors heat loss through perspiration.
b. Their renal function is not fully developed, and heat is lost in the urine.
c. They have a thin layer of subcutaneous fat that provides poor insulation.
d. Their small body surface area produces heat loss more rapidly than an adult's.
Newborns are prone to heat loss because they have a large body surface area in relation to their weight. Their skin is thin, blood vessels are close to the surface, and there is little subcutaneous fat for insulation.
The nurse assessing a newborn recognizes that the most critical physiologic change required of the newborn is:
a. Initiation and maintenance of respiration
b. Closure of fetal shunts in the circulatory system
c. Maintenance of a stable temperature
d. Full function of the immune system at birth
To live independently from the mother, pulmonary ventilation must be quickly established through lung expansion. The first breath of a healthy newborn occurs within seconds after birth, and by 30 seconds of life the neonate usually is breathing well on his or her own.
The nurse is transporting a newborn from the delivery room to the nursery in a closed, warm incubator. This is done because the nurse recognizes that a primary source of heat loss for the neonate is due to:
a. Convection
b. Evaporation
c. Conduction
d. Radiation
Convection is transfer of heat to the surrounding cooler air, so newborns may be transported in closed, warm incubators and wrapped warmly when in bassinets.
What would be considered normal vital signs for a newborn 1 hour after birth?
a. HR 80 beats/minute, RR 40 breaths/minute
b. HR 110 beats/minute, RR 20 breaths/minute
c. HR 140 beats/minute, RR 50 breaths/minute
d. HR 180 beats/minute, RR 70 breaths/minute
Normal values for a newborn are heart rate (HR) 110 to 160 beats/minute and respiratory rate 30 to 60 breaths/minute.
The circumference of the newborn infant's head is expected to be:
a. Smaller than the chest
b. Larger than the chest by 6 cm (2.4 inches)
c. Equal to or slightly larger than the chest
d. Variable according to the infant's weight
The newborn's head circumference should be equal to or greater than the chest circumference. It should not exceed the chest measurement by more than 4 cm (1.6 inches).
Part of the health assessment of a newborn includes observing his or her breathing pattern. A full-term newborn's breathing pattern is primarily:
a. Deep with a regular rhythm
b. Diaphragmatic with chest retraction
c. Chest breathing with nasal flaring
d. Abdominal with synchronous chest movements
Because neonatal respirations are abdominal or diaphragmatic, the nurse visually observes the rise and fall of the baby's abdomen. Movement of the chest and abdomen should be synchronous. Nasal flaring and chest retractions are signs of respiratory distress.
As part of the newborn assessment, the nurse inspects the gluteal and popliteal folds of the hips to assess for:
a. Opisthotonos
b. Neurologic development
c. Congenital hip dysplasia
d. Muscle development
Asymmetric skin folds warrant further evaluation to confirm or rule out hip dysplasia.
The newborn is noted to have a prominent clitoris with a small labia majora. The nurse realizes this is characteristic of a:
a. Large-for-gestational-age infant
b. Preterm infant
c. Small-for-gestational-age infant
d. Postterm infant
A prominent clitoris with small labia majora is a characteristic of prematurity.
A preterm infant is more likely than a full-term infant to have:
a. Closure of shunts
b. Descended testes
c. Inefficient thermogenesis
d. Complete wrist flexion
The only option characteristic of the preterm newborn is inefficient thermogenesis. This is true because the preterm infant has less brown fat and a larger body surface with a head larger in proportion to the body than that of a full-term newborn; also, the extremities are often extended rather than flexed, which increases the exposed body surface.
The nurse recognizes the primary reason that an infant delivered at 33 weeks' gestation is at high risk for respiratory distress is that:
a. The rib cage is poorly developed.
b. Surfactant is inadequate to maintain lung inflation.
c. The central nervous system is not sensitive to low oxygen levels.
d. Lack of motor activity predisposes the infant to the hazards of immobility.
Before the thirty-fifth week, the fetal lungs are not usually capable of producing enough surfactant to prevent alveolar collapse on expiration, resulting in reduced exchange of oxygen and carbon dioxide. This causes hypoxia, decreased pulmonary blood flow, and depletion of the newborn's energy.
A preterm infant is diagnosed with necrotizing enterocolitis. The parents ask the nurse to explain this condition. Accurate information would include:
a. Intravenous feedings will be used for a while to permit the intestines to heal.
b. The feeding tube could have damaged the stomach lining.
c. The infant formula may have been too rich for the baby's system.
d. This is a mild infection that is easily treated with antibiotics.
It is thought that hypoxia that is common with prematurity damages the cells of the intestine so that it develops ischemic changes and does not produce adequate mucus. This permits bacteria from feedings to invade the intestinal wall. To permit healing, feedings are given intravenously. It is a life-threatening infection.
Although the signs of necrotizing enterocolitis (NEC) are relatively nonspecific, some generalized signs that nurses caring for preterm newborns should be alert for include:
a. Hypertension, tachypnea, ruddy skin color
b. Abdominal distention, absent bowel sounds, bloody stools
c. Hypertonia, tachycardia, metabolic alkalosis
d. Constipation, no residual with feedings, hyperactive bowel sounds
Signs of NEC include abdominal distention with increased residual feeding (not decreased), diminished or absent bowel sounds (not hyperactive), diarrhea (not constipation), and blood in the stool.
A preterm newborn is more likely to develop hyperbilirubinemia than a term newborn because the former has:
a. Impaired ability to manufacture immunoglobulins
b. Poor hepatic clearance of bilirubin and excess free fatty acids
c. Decreased liver glycogen stores
d. Immature kidneys, reducing excretion of bilirubin
Poor hepatic clearance of bilirubin and reduced fluid intake (small feedings) can inhibit the removal of bilirubin in the intestines (not kidneys). Excess free fatty acids, released through cold stress, compete with bilirubin for protein-binding sites, which displace bilirubin into circulation.
An infant in the newborn nursery has hyperbilirubinemia. Which assessment would the nurse recognize as pathologic hyperbilirubinemia?
a. Jaundice was present the first day of life.
b. The infant was born at 37 weeks' gestation.
c. The total serum bilirubin level was 6 mg/dL on the second day of life.
d. The total serum bilirubin has decreased 6 mg/dL over the past 3 days.
Pathologic hyperbilirubinemia may be present the first day of life, whereas physiologic hyperbilirubinemia occurs around the third day of life and is usually transient. Although preterm infants are more likely to have pathologic hyperbilirubinemia, it can affect term infants as well. A serum bilirubin level of 6 mg/dL is normal for a newborn. The condition would be considered pathologic if the serum bilirubin went up (not down) by more than 5 mg/dL.
All of the following mothers have recently given birth. Which newborn is most likely to have erythroblastosis fetalis?
a. An Rh+ mother has an Rh+ baby.
b. An Rh+ mother has an Rh- baby.
c. An Rh- mother has an Rh- baby.
d. An Rh- mother has an Rh+ baby.
When an Rh-negative mother is carrying an Rh-positive fetus, the mother makes antibodies against the Rh-positive red blood cells. The maternal antibodies enter the fetal circulation and destroy the fetal red blood cells.
The direct Coombs' test is done to assess the:
a. Maturity of the baby's lungs
b. Total bilirubin of the baby's blood
c. Amount of Rh-positive antibodies in the mother's blood
d. Presence of antibody-coated Rh-positive red blood cells in the baby's blood
The direct Coombs' test determines whether the infant has hemolytic disease caused by Rh incompatibility by revealing the presence of antibody-coated Rh-positive red blood cells in the baby's blood. An indirect Coombs' test measures the amount of Rh-positive antibodies in the mother's blood.
The purpose of phototherapy is to:
a. Stimulate red blood cell production.
b. Destroy Rh-positive antibodies.
c. Reduce serum bilirubin.
d. Promote vitamin D synthesis.
High-intensity light decreases bilirubin levels by converting unconjugated bilirubin into photobilirubin, which is transported to the liver where it combines with bile and is excreted in the feces.
When an infant is receiving phototherapy with standard high-intensity lights, the nurse should explain to the parents that:
a. The infant's eyes will be covered because the bright light would prevent sleep.
b. The infant can be removed from the light for feeding and short visits.
c. Lotion can be applied to moisturize the skin before treatments.
d. The infant will remain under the light at all times.
The infant can be removed from the light (and the eye patches removed) for feeding and for short visits with parents. The eyes are covered during treatments to prevent damage to the eyes from the lights. Lotions and oils are not applied because they may cause burning of the skin.
A male infant is receiving phototherapy for the treatment of hyperbilirubinemia. Which action by the student nurse indicates that she does not fully understand the standard of care for this infant?
a. Changes the infant's position every 2 hours during therapy
b. Administers feeding to the infant while under the light
c. Covers the infant's scrotal area during therapy
d. Leaves the infant unclothed during therapy
All options are correct except administering formula to the infant while under the light. The infant should be removed from under the light for feedings and short parental visits.
A pregnant woman who is Rh negative asks the nurse about the injection she is to receive during her pregnancy. Which response is most appropriate?
a. "The injection will be given into your subcutaneous tissue."
b. "The injection will be given when you are at thirty-six weeks' gestation."
c. "The injection is given to prevent a serious disease in your unborn baby."
d. "The injection is given to prevent you from contracting a serious blood disorder."
Rho(D) immune globulin (RhoGAM) is given to Rh-negative women at 28 weeks' gestation to prevent erythroblastosis fetalis in the newborn. It is given intramuscularly. The injection protects the fetus, not the mother.
After watching the nurse place ointment in his baby's eyes, a new father asks what the medication is and why it is needed. The nurse explains that the purpose of the erythromycin ophthalmic ointment is to:
a. Prevent the baby's eyelids from sticking together and to help the baby see
b. Prevent infection of the baby's eyes with gonorrhea and Chlamydia potentially acquired from the birth canal
c. Destroy an infection caused by staphylococci that can cause blindness
d. Prevent potentially harmful exudate from invading the tear ducts, leading to dry eyes
The newborn can acquire an eye infection, such as Chlamydia or gonorrhea, when passing through an infected birth canal. Prophylaxis against gonococcal ophthalmia neonatorum, an infection that can cause blindness, is required for all newborns. Erythromycin ophthalmic ointment is commonly used because it is also effective against the Chlamydia organism.
Which statement is true of ectopic pregnancy?
a. A woman who has had an ectopic pregnancy will not be able to conceive again.
b. The ovum will not develop, so there is no risk to the woman.
c. The fertilized ovum is implanted outside of the uterus.
d. The main sign is heavy vaginal bleeding.
With an ectopic pregnancy, the fertilized ovum implants in tissue outside of the uterus, usually the fallopian tube. The woman is at risk for hemorrhage, shock, and death. Vaginal bleeding is often minimal because the blood loss is inside of the abdominal cavity and has no way to exit the body. Every effort is made to preserve an affected fallopian tube, and future conception possible with one fallopian tube.
Causes of spontaneous abortion can include:
a. Acute maternal infection
b. Uterine atony
c. Pregnancy-induced hypertension
d. Hyperthyroidism
Causes of spontaneous abortion include genetic defects; defective ovum or sperm; defective implantation; maternal chronic conditions, acute infections, or nutritional deficiencies; abnormalities of maternal reproductive organs; endocrine deficiencies; and blood group dyscrasias. Psychological and physiologic trauma has also been implicated as a cause for spontaneous abortion.
During an assessment of an infant born to an intravenous drug abuser, the nurse should recognize which sign(s) and/or symptom(s) as indicative of drug withdrawal?
a. Plethora and a high-pitched, shrill cry
b. Jaundice and sneezing 3 days after delivery
c. Tremor and hyperactive reflexes
d. Restlessness and seedy, yellow-brown stools
Clinical manifestations of withdrawal in a neonate reflect autonomic nervous system hyperirritability, including tremor; restlessness; sneezing; hyperactive reflexes; and a high-pitched, shrill cry. Plethora is typically associated with maternal diabetes. Jaundice is a common finding with hyperbilirubinemia. Seedy, yellow-brown stools are normal for a neonate.
Which statement is accurate about the abuse of substances during pregnancy?
a. Substance abuse is most damaging to the fetus during the third trimester.
b. Use of alcohol, tobacco, marijuana, and cocaine can cause fetal growth retardation.
c. Inhaled substances are more likely than intravenous substances to cross the placental barrier.
d. Newborn infants rarely experience withdrawal after birth to a mother who has used addictive substances.
Alcohol, tobacco, marijuana, and cocaine can cause fetal growth retardation. The fetus is at greatest risk in the first trimester. Intravenous substances are more likely to cross the placental barrier. The newborn of an addicted mother will experience withdrawal from the substances she was using.
The nurse suspects that the postpartum patient has a hematoma. Which assessment finding(s) would be relevant to this conclusion? (Select all that apply.)
a. Complains of vaginal pain
b. Difficulty urinating
c. Firm fundus
d. Moderate lochia
e. Rectal pressure
A, B, E
Hematoma, a collection of blood within the tissues, may result from injury to blood vessels in the perineum or in the vagina. Perineal or vaginal pain, rather than apparent bleeding, is a distinguishing characteristic of a hematoma. The woman may not be able to void due to pressure on the urethra, or she may feel the urge to have a bowel movement due to pressure on the rectum. A firm fundus and moderate lochia are normal assessment findings in the postpartum patient.
During a postpartum assessment, the nurse suspects a vaginal or cervical laceration. This conclusion is based on which assessment(s)? (Select all that apply.)
a. Bright red vaginal bleeding
b. Firmly contracted uterus
c. Perineal pain
d. Dark red vaginal bleeding
e. Pulse rate of 100 beats/minute
A, B, E
Bright red vaginal bleeding in the presence of a firmly contracted uterus is suggestive of a laceration. A pulse rate of 100 beats/minute may be an early sign of shock. Perineal pain may be associated with a hematoma or episiotomy. Dark red vaginal bleeding is characteristic of lochia.
A postpartum patient complains of perineal pain. Her uterus is firm, and she has minimal vaginal bleeding. She states that she feels like she needs to urinate and have a bowel movement but has been unable to do either. The nurse suspects that the patient most likely has:
a. A hematoma
b. Subinvolution
c. A postpartum infection
d. Disseminated intravascular coagulation
These are classic signs and symptoms of hematoma. A hematoma is a collection of blood within the tissues that may result from injury to blood vessels in the perineum or vagina. Perineal pain, rather than noticeable bleeding, is a distinguishing characteristic of a hematoma, and the uterus remains firm. Pressure on the urethra may cause difficulty voiding, and pressure on the rectum may feel like the need to have a bowel movement.