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Terms in this set (40)The nurse is developing a teaching plan for a client who has decided to bottle feed her newborn. Which of the following would the nurse include in the teaching plan to facilitate suppression of lactation? d. Instructing her to apply ice packs to both breasts every other hour A client who is breast-feeding her newborn tells the nurse, "I notice that when I feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now?" Which
response by the nurse would be most appropriate? d. "The baby's sucking releases a hormone that causes the uterus to contract." The nurse is making a follow-up home visit to a woman who is 12 days postpartum. Which of the following would the nurse expect to find when assessing the client's fundus? A) Cannot be palpated By the end of 10 days, the fundus usually cannot be palpated because it has descended into the true pelvis. When the nurse is assessing a postpartum client approximately 6 hours after delivery, which finding would warrant further investigation? C) Heart rate of 120 beats/minute Tachycardia in the postpartum woman warrants further investigation. It may indicate hypovolemia, dehydration, or hemorrhage. Deep red, fleshy-smelling lochia is a normal finding 6 hours postpartum. Voiding in small amounts such as less than 150 cc would indicate a problem, but 350 cc would be appropriate. Profuse sweating also is normal during the postpartum period. The nurse develops a teaching plan for a postpartum client and includes teaching about how to perform Kegel exercises. The nurse includes this information for
which reason? C) Improve pelvic floor tone Kegel exercises help to improve pelvic floor tone, strengthen perineal muscles, and promote healing, ultimately helping to prevent urinary incontinence later in life. Kegel exercises have no effect on lochia, involution, or pain. A group of students
are reviewing the process of breast milk production. The students demonstrate understanding when they identify which hormone as responsible for milk let-down? D) Oxytocin Oxytocin is released from the posterior pituitary to promote milk let-down. Prolactin levels increase at term with a decrease in estrogen and progesterone; estrogen and progesterone levels decrease after the placenta is delivered. Prolactin is released from the anterior pituitary gland and initiates milk production. A postpartum client has a fourth-degree perineal laceration. The nurse would expect which of the following medications to be ordered? C) Docusate (Colace) A stool softener such as docusate (Colace) may promote bowel elimination in a woman with a fourth-degree laceration, who may fear that bowel movements will be painful. Ferrous sulfate would be used to treat anemia. However, it is associated with constipation and would increase the discomfort when the woman has a bowel movement. Methylergonovine would be used to prevent or treat postpartum hemorrhage. Bromocriptine is used to treat hyperprolactinemia. A nurse is making a home
visit to a postpartum woman who delivered a healthy newborn 4 days ago. The woman's breasts are swollen, hard, and tender to the touch. The nurse documents this finding as which of the following? B) Engorgement Engorgement is the process of swelling of the breast tissue as a result of an increase in blood and lymph supply as a precursor to lactation (Figure 15.4). Breast engorgement usually peaks in 3 to 5 days postpartum and usually subsides within the next 24 to 36 hours (Chapman, 2011). Engorgement can occur from infrequent feeding or ineffective emptying of the breasts and typically lasts about 24 hours. Breasts increase in vascularity and swell in response to prolactin 2 to 4 days after birth. If engorged, the breasts will be hard and tender to touch. Involution refers to the process of the uterus returning to its prepregnant state. Mastitis refers to an infection of the breasts. Engrossment refers to the bond that develops between the father and the newborn. A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a pulse of 60 beats per minute. Which of these actions should the nurse take? A) Document the finding, as it is a normal finding at this time. A) Document the finding, as it is a normal finding at this time. Pulse rates of 40 to 80 beats per minute (bmp) are normal during the first week after birth. This pulse rate is called puerperal bradycardia. During pregnancy, the heavy gravid uterus causes a decreased flow of venous blood to the heart. After giving birth, there is an increase in intravascular volume. The cardiac output is most likely caused by an increased stroke volume from the venous return now. The elevated stroke volume leads to a decreased heart rate. To decrease the pain associated with an episiotomy immediately after birth, which action by the nurse would be most appropriate? C) Apply an ice pack to the site. An ice pack is the first measure used after a vaginal birth to provide perineal comfort from edema, an episiotomy, or lacerations. Warm blankets would be helpful for the chills that the woman may experience. Encouraging her to void promotes urinary elimination and uterine involution. A warm sitz bath is effective after the first 24 hours. A nurse is completing a
postpartum assessment. Which finding would alert the nurse to a potential problem? C) Temperature of 101° F Typically, the new mother's temperature during the first 24 hours postpartum is within the normal range. Some women experience a slight fever, up to 38º C (100.4º F), during the first 24 hours. A temperature above 38º C (100.4º F) at any time or an abnormal temperature after the first 24 hours may indicate infection and must be reported. Foul-smelling lochia or lochia with an unexpected change in color or amount, shortness of breath, or respiratory rate below 16 or above 20 breaths per minute would also be a cause for concern. The goal of pain management is to have the woman's pain scale rating maintained between 0 to 2 points at all times, especially after breast-feeding. After a normal labor and birth, a client is discharged from the hospital 12 hours later. When the community health nurse makes a home visit 2 days later, which finding would alert the nurse to the need for further intervention? A) Presence of lochia serosa B) Frequent scant voidings Infrequent or insufficient voiding may be a sign of infection and is not a normal finding on the second postpartum day. Lochia serosa, a firm fundus below the umbilicus, and milk filling the breasts are expected findings. When reviewing the medical record of a postpartum client, the nurse notes that the client has experienced a third-degree laceration. The nurse understands that the laceration extends to which of the following? C)Through the anal sphincter muscle A third-degree laceration extends through the anal sphincter muscle. A first-degree laceration involves only the skin and superficial structures above the muscle. A second-degree laceration extends through the perineal muscles. A fourth-degree laceration continues through the anterior rectal wall. After reviewing information about postpartum blues, a group of students demonstrate understanding when they state which of the following about this condition? ... The nurse places a warmed blanket on the scale when weighing a newborn to minimize heat loss via which mechanism? A) Evaporation B) Conduction Using a warmed cloth diaper or blanket to cover any cold surface, such as a scale, that touches a newborn directly helps to prevent heat loss through conduction. Drying a newborn and promptly changing wet linens, clothes, or diapers help reduce heat loss via evaporation. Keeping the newborn out of a direct cool draft, working inside an isolette as much as possible, and minimizing the opening of portholes help prevent heat loss via convection. Keeping cribs and isolettes away from outside walls, cold windows, and air conditioners and using radiant warmers while transporting newborns and performing procedures will help reduce heat loss via radiation. A client expresses concern that her 2-hour-old newborn is
sleepy and difficult to awaken. The nurse explains that this behavior indicates which of the following? A) Normal progression of behavior From 30 to 120 minutes of age, the newborn enters the second stage of transition, the period of decreased responsiveness or that of sleep or a decrease in activity. More information would be needed to determine if hypoglycemia, a physiologic abnormality, or inadequate oxygenation was present. Twenty minutes after birth, a baby begins to move his head from side to side, making eye contact with the mother, and pushes his tongue out several times. The nurse interprets this as indicating which of the following? A) A good time to initiate breast-feeding A) A good time to initiate breast-feeding The newborn is demonstrating behaviors indicating the first period of reactivity, which usually begins at birth and lasts for the first 30 minutes. This is a good time to initiate breast-feeding. Decreased responsiveness occurs from 30 to 120 minutes of age and is characterized by muscle relaxation and diminished responsiveness to outside stimuli. There is no indication that the newborn may experience gagging or vomiting. Chilling would be evidenced by tachypnea, decreased activity, and hypotonia. A new mother is changing the diaper of her 20-hour-old newborn and asks why the stool is almost black. Which response by the nurse would be most appropriate? B) "This is meconium stool, normal for a newborn." Meconium is greenish-black and tarry and usually passed within 12 to 24 hours of birth. This is a normal finding. Iron can cause stool to turn black, but this would not be the case here. The stool is a normal occurrence and does not need to be checked for blood or reported. The nurse is assessing the respirations of several newborns. The nurse would notify the health care provider for the newborn with which respiratory rate at rest? D. 68 breaths per minute The parents of a newborn become concerned when they notice that their baby seems to stop
breathing for a few seconds. After confirming the parents' findings by observing the newborn, which of the following actions would be most appropriate? B) Assess the newborn for signs of respiratory distress Although periods of apnea of less than 20 seconds can occur, the nurse needs to gather additional information about the newborn's respiratory status to determine if this finding is indicative of a developing problem. Therefore, the nurse would need to assess for signs of respiratory distress. Once this information is obtained, then the nurse can notify the health care provider or explain that this finding is an expected one. However, it would be inappropriate to tell the parents not to worry, because additional information is needed. Also, telling them not to worry ignores their feelings and is not therapeutic. Prior to discharging a 24-hour-old newborn, the nurse assesses her respiratory status. Which of the following would the nurse expect to assess? A) Respiratory rate 45, irregular A) Respiratory rate 45, irregular Typically, respirations in a 24-hour-old newborn are symmetric, slightly irregular, shallow, and unlabored at a rate of 30 to 60 breaths/minute. The breathing pattern is primarily diaphragmatic. Nasal flaring, rates above 60 breaths per minute, and crackles suggest a problem. When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8ºF, an apical pulse of 114 beats/minute, and a respiratory rate of 60
breaths/minute. Which nursing diagnosis takes highest priority? A) Hypothermia related to heat loss during birthing process NEWBORN VITAL SIGNS: While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of the soft tissues of his scalp that crosses suture lines. The nurse documents this finding as: C) Caput succedaneum Caput succedaneum is localized edema on the scalp, a poorly demarcated soft tissue swelling that crosses the suture lines. Molding refers to the elongated shape of the fetal head as it accommodates to the passage through the birth canal. Microcephaly refers to a head circumference that is 2 standard deviations below average or less than 10% of normal parameters for gestational age. Cephalhematoma is a localized effusion of blood beneath the periosteum of the skull. A nurse is providing
teaching to a new mother about her newborn's nutritional needs. Which of the following would the nurse be most likely to include in the teaching? (Select all that apply) C) Feed the
newborn every 2 to 4 hours during the day. The nurse administers vitamin K intramuscularly to the newborn based on which of the following rationales? D) Promote blood clotting Vitamin K promotes blood clotting by increasing the synthesis of prothrombin by the liver. RhoGAM prevents Rh sensitization. Erythropoietin stimulates erythropoiesis. Phototherapy enhances bilirubin breakdown. During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse documents this finding as which of the following? B) Mongolian spots Mongolian spots are blue or purple splotches that appear on the lower back and buttocks of newborns. Milia are unopened sebaceous glands frequently found on a newborn's nose. Stork bites are superficial vascular areas found on the nape of the neck and eyelids and between the eyes and upper lip. Birth trauma would be manifested by bruising, swelling, and possible deformity. Assessment
of a newborn reveals uneven gluteal (buttocks), skin creases and a "clunk" when Ortolani's maneuver is performed. Which of the following would the nurse suspect? B) Developmental hip dysplasia A "clunk" indicates the femoral head hitting the acetabulum as the head reenters the area. This, along with uneven gluteal creases, suggests developmental hip dysplasia. These findings are not a normal variation and are not associated with slipping of the periosteal joint or overriding of the pelvic bone. The nurse is assessing the skin of a newborn and notes a rash on the newborn's face, and chest. The rash consists of small papules and is scattered with no pattern. The nurse interprets this finding as which of the following? C) Erythema toxicum A new mother who is breast-feeding her newborn asks the nurse, "How will I know if my baby is drinking enough?" Which response by the nurse would be most appropriate? C. "He should wet between 6 to 12 diapers each day." The father is giving Tom a bath when his wife remarks, "his hands and feet are so blue. Something is wrong with him" which of the following statements by the father reflects a correct understanding of the situation? ... To assess the pulse rate of a newborn the nurse should ... The primary reason for using erythromycin ophthalmic ointment for prophylactic eye care is because GONORRHEA, CHLAMYDIA, PINK EYE Prior to discharge, the nurse plans to discuss sudden infant death syndrome with the parents of Garret. She should include which of the following as a major risk factor? ... Twenty four hours after birth the nurse is preparing to conduct an assessment of baby Briget. To better acquaint the parents with the newborn, the nurse should plan to ... Baby Noah is 36 hours old. When cleansing Bryan's perineal area, the nurse is unable to retract the foreskin on his uncircumcised penis easily. At this time the nurse should: ... When assessing Jamie, a 4-day-old infant, the nurse notes that his umbilical cord is shriveled and black. The nurse should: ... Newborn has some defined bruise-like areas across the buttocks. The nurse suspects that these discoloration's are related to: ... On the afternoon following the birth of her daughter, a mother states to the nurse. "The nursery nurse told me that my baby has to have an injection of vitamin K. She's so small to be getting a shot. Why does she have to have it?" The nurse's most appropriate response would be: ... The nurse, observing a sleeping newborn, notes periods of irregular breathing and occasional twitching movements of the arms and legs. The neonate's heart rate is 150 beats per minute, the respiratory rate is 50 breaths per minute; and the glucose strop is 60mg/100ml. The nurse's most appropriate assessment would be: ... Babies that are breast fed have high IQ scores than babies who are just formula fed. ... Sets with similar termsMaternity Nclex questions68 terms crystalrose_rivera ch 17 pillitteri43 terms hellomynameisjr Other sets by this creatorLEADERSHIP FINAL CH 2112 terms karingarcia02 LEADERSHIP FINAL CH 208 terms karingarcia02 LEADERSHIP FINAL CH7 terms karingarcia02 LEADERSHIP FINAL CH 1814 terms karingarcia02 Recommended textbook solutionsClinical Reasoning Cases in Nursing7th EditionJulie S Snyder, Mariann M Harding 2,512 solutions
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Which statement would the nurse include when teaching a new mother about postpartum blues quizlet?
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