Maternal exam 2 module 4,5,6,

A woman who is two days postpartum has painful hemorrhoids. Which position would the nurse suggest she use for resting?

sims position

 The nurse notices that a new mother who is beginning postpartum day 2 handles the

newborn tentatively and does not kiss the child when holding him. What should the nurse suspect as the probable reason for this behavior?

reacting normally to accepting a new child

While documenting client care, the nurse notes that a postpartum client is accepting

the birth of the child well. What did the nurse most likely observe to come to this

conclusion?

turns the face to meet the infant's eyes when holding the baby-  Looking directly at the newborn's face, with direct eye contact or the en face position,

is a sign a woman is beginning effective attachment

The nurse is assessing the fundus of a client on postpartum day 1. What should the nurse expect when palpating the fundus?

fundus one fingerbreadth below umbilicus and firm

 When assessing a postpartum client who was diagnosed with a cervical laceration that has been repaired, what sign should the nurse report as a possible development of hypovolemic shock?

weak and rapid pulse

Which assessment on the third postpartum day would indicate to the nurse that a woman is experiencing uterine subinvolution?

Her uterus is at the level of the umbilicus.

A postpartum woman is prescribed an antibiotic because of endometritis. Her breastfed infant should be observed particularly for which of the following?

signs of oral candidiasis (thrush) and easy bruising

A postpartum woman is developing a thrombophlebitis in her right leg. Which

assessments would the nurse make to detect this?

Assess for pedal edema.-

A postpartum woman is placed on an anticoagulant to prevent further clot formation.

She asks the nurse if she will be able to continue breastfeeding. The nurse's best response would be that

it depends on the type of anticoagulant she is taking.-Heparin, for example, does not pass into breast milk, yet warfarin (coumadin) does.

A client who gave birth 5 hours ago has completely saturated a perineal pad within 15

minutes. Which action by the nurse should be implemented first?

Assess the fundus

 The nurse is planning interventions to prevent the onset of urinary retentionin a

postpartum client. Why are these interventions needed?

Decreased bladder sensation results from edema because of the pressure of birth

 After delivery, a client is diagnosed with postpartal gestational hypertension. What care will the nurse provide to this client? Select all that apply.

Maintain on bed rest.

Monitor urine output.

Administer magnesium sulfate as prescribed.

Administer antihypertensive medication as prescribed.

 The nurse is instructing a postpartum client on observations to report to the health care provider that could signify retained placental fragments. Which client statement indicates that teaching has been effective?

"If the drainage changes from clear to bright red, I am to call the doctor."

A postpartum client is diagnosed with a vaginal laceration. What intervention will the

nurse provide to the client at this time?

Insert an indwelling urinary catheter.

 On inspection, the nurse notes that a newborn has a normal newborn head/body proportion. This proportion for the head is:

one-fourth his total length.

When examining a newborn's eyes, the nurse would expect which assessment?

follows a light to the midline- Newborns do not usually follow past the midline until 3 months of age. They do not tear.

 The nurse notices that a newborn has a white discharge from his breasts. The nurse would explain to his parents that this is

caused by his mother's hormones.- Both male and female newborns may have a milky breast discharge from being under the influence of female hormones in utero.

The nurse records a newborn's Apgar score at birth. A normal 1-minute Apgar score is:

7 to 10.

On an Apgar evaluation, how is reflex irritability tested?

flicking the soles of the feet and observing the response-

 When teaching a mother to care for her newborn's umbilical cord, which of the following instructions would you include?

keeping it dry

The nurse is assessing a term newborn. Which finding should the nurse expect when

assessing the patterns of sole creases?

creases on two-thirds of the foot

 During a home visit, a new mother is concerned that, after three meconium stools, her

newborn has had a bright green stool. What should the nurse explain to the mother?

This is a normal finding.- After meconium stools, the newborn's stool changes in color and consistency. This is a transitional stool and is green. It might look like diarrhea. This does not indicate that the baby is developing an allergy to breast milk or that the child needs to be isolated until the stool can be cultured.

 The nurse is planning to instruct a new mother on care of the newborn. Which instructions support the 2030 National Health Goals for the newborn? Select all that apply.

Place the infant on the back to sleep.

Continue to breast-feed the baby until age 6 months.

Do not provide the baby with a bottle while falling asleep.

 After completing a physical assessment of a newborn, the nurse notifies the health care provider about which finding?

scaphoid abdomen- A scaphoid or sunken

appearance suggests missing abdominal contents or a diaphragmatic hernia (bowel or other abdominal organs positioned in the chest instead of the abdomen)

Which assessment finding indicates to the nurse that a newborn has hip

subluxation?

inability of the right hip to abduct-  If the hip joint seems to lock short of this distance of 180 degrees, hip subluxation is suggested. Inward rotation of the right foot, crying when straightening the leg, or drawing the legs underneath when prone does not indicate hip subluxation.

The nurse is inspecting a male newborn's genitalia. Which action should the nurse

avoid when conducting this assessment?

retracting the foreskin over the glans to assess for secretions- In most male newborns, the foreskin slides back poorly from the meatal opening, so the nurse should not try to retract it. The nurse should inspect the area for irritated skin, inspect the urethral opening, and palpate the testes in the scrotal sac

 When assessing a newborn's 5-minute Apgar score, how will the nurse determine

reflex irritability?

 slapping the soles of the feet and observing the response

A client who has just given birth to her first baby asks the nurse for help with breastfeeding. Which nursing diagnosis would be the most appropriate for the client at this time?

health-seeking behaviors

The nurse is visiting a new mother who has been home with a new infant for 4 days.

Which observation indicates that the mother's home environment was inadequately assessed prior to being discharged from the hospital?

The baby sleeps with the mother in bed.

A newborn is prescribed to receive vitamin K (Aqua-Mephyton) 0.5 mg intramuscularly.

What should the nurse do when providing this medication to the newborn?

Administer the medication into the anterolateral muscle of the thigh

A new mother does not want the baby to return to the nursery because of the fear of

someone taking the baby without her permission. What should the nurse explain to the mother to allay her fears?

Both the mother and infant have identification bands that need to match.

 The nurse assesses the head circumference of a mature newborn. Which

measurement does the nurse identify as a possible cause for concern?

37.4

Measurements vary, but in a mature newborn, the head circumference is usually 34 to

35 cm (13.5 to 14 in.). A mature newborn with a head circumference greater than 37 cm (14.8 in.)

or less than 33 cm (13.2 in.) should be carefully assessed for neurologic involvement, although some well newborns have these measurements.

The nurse is questioning the effective bonding of a client and their 2-day-old infant after noting signs of impaired bonding and attachment. Which action does the nurse find concerning?

client calling the infant "it" or "they”

A nurse is providing discharge teaching to a newly postpartum client who is bottle-feeding their newborn. Which statement should the nurse include in their teaching?

"You will be able to gradually increase your physical activity starting in 4 weeks."

Prior to discharge from the hospital, a nurse is checking the fundal height for a new parent who delivered 2 days ago. The nurse would anticipate which finding?

• two fingerbreadths below the umbilicus

A G4P4 client calls the nurse’s station reporting uterine pain following birth. When the nurse responds to the call, the client reports that they are having what feels like labor pains again off and on. What would be the nurse’s response?

Explain to the client that parents who have had several children prior to their current delivery often experience afterpains, which is where the uterus is contracting and relaxing at intervals.

A nurse is caring for a client who is nursing their newborn. The client reports afterpains. Secretion of which substance causes afterpains?

• oxytocin

During a postpartum home visit, a client tells the nurse that their hip joints are sore, just like they were when the client was pregnant. Which information will the nurse likely include when teaching the client about this condition? Select all that apply.

"This soreness should go away in about 6 to 8 weeks.

"Let me show you how to use good body mechanics to lessen the problem."

When the nurse is assessing a postpartum client approximately 6 hours after birth, which finding warrants further investigation?

blood pressure 90/50 mm Hg

A client who just gave birth has difficulty sleeping despite exhaustion from labor. What is a potential cause(s) of this inability to rest? Select all that apply.

• excess fatigue and overstimulation by visitors

• inadequate pain relief

• crying newborn

• frequent trips to the bathroom due to diuresis

A nurse is caring for a client on the second day postpartum. The client informs the nurse that they are voiding a large volume of urine frequently. Which factor should the nurse identify as a potential cause for urinary frequency?

• postpartum diuresis

When teaching parents about their newborn, the nurse describes the development of a close emotional attraction to a newborn by the parents during the first 30 to 60 minutes after birth. The nurse refers to this process by which term?

bonding

A nurse is providing discharge teaching to a newly postpartum client who is bottle-feeding their newborn. Which statement should the nurse include in their teaching?

"You will be able to gradually increase your physical activity starting in 4 weeks."

A client who delivered their newborn by cesarean birth is admitted to the postpartum unit. During the delivery, the client received two doses of morphine sulfate. The nurse notes that the client’s respiratory rate is 11 and their oxygen saturation is 93%. What should the nurse do first?

Notify the health care provider of the findings.

A postpartum client calls the nurse and reports that their right calf hurts whenever they walk around the room or in the hall. What assessment(s) will the nurse perform for to check for a deep vein thrombosis? Select all that apply.

• Feel the right calf for increased warmth.

• Measure the diameter of both calves.

• Note any reddened areas on the right calf.

A postpartum client has a fourth-degree perineal laceration. The nurse expects which medication to be prescribed?

docusate

A nurse is reviewing the medical record of a postpartum client in preparation for assessment. Which factor would the nurse identify as increasing the client's risk for infection? Select all that apply.

• denuded endometrial arteries

• urinary stasis

• episiotomy

While making a follow-up home visit to a client in their first week postpartum, the nurse notes that the client has lost 5 lb (2.5 kg). Which reason for this loss is likely?

diuresis

The nurse is assessing a 2-day-old newborn who is irritable, pale, and not interested in eating. Which of the following additional signs is an indicator of bacterial infection in the newborn?

Subnormal temperature

Assisting in the initiation of breastfeeding is a role of the nurse. When should the nurse recommend that a newborn have the initial feeding?

Within the first 30 minutes after birth

A newborn was resuscitated at birth due to poor respiratory effort. Which assessment data would concern the nurse the most at 6 hours after birth?

Body temperature of 98.0°F- A lower than normal body temperature creates a need for increased metabolism and increased need for oxygen as well as possible acidosis, resulting in a decrease in surfactant production and a risk for hypoglycemia. Acrocyanosis and a respiratory rate of 40 breaths/min are within the normal range for this time frame, as is sluggishness with an initial feeding.

A nurse has been assigned to the care of two newborn infants who are 38 weeks’ gestation. One is small-for-gestational-age and one is large-for gestational-age. The nurse knows that they both are most likely at risk for all of the following complications except

Intraventricular hemorrhage

• The nurse is assessing a newborn by auscultating the heart and lungs. Which natural phenomenon will the nurse explain to the parents is happening in the cardiovascular system?

Pressure changes occur and result in closure of the ductus arteriosus.Pressure changes occur and result in closure of the ductus arteriosus.

At what point should the nurse expect a healthy newborn to pass meconium?

within 24 hours after birthwithin 24 hours after birth

During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse interprets this finding as

• congenital dermal melanocytosis (slate gray nevi).

The nursing instructor is teaching a class on the physiologic prosperities involved with the birthing process. The instructor determines the session is successful when the students correctly match surfactant with which function?

It keeps alveoli from collapsing with breaths.

After the birth of a newborn, which action does the nurse do first to assist in thermoregulation?

Dry the newborn thoroughly.

The nurse is caring for a newborn who has a large surface area to body mass ratio. What action will the nurse take to help this newborn regulate temperature?

• Assure the newborn has a cap on the head and is kept covered.

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A client who is about to be discharged after a vaginal birth notices a flea-like rash on their newborn's chest that consists of tiny red lesions all across the nipple line. What is the best response from the nurse when explaining this to the client?

"It is a normal skin finding in a newborn."

What supplies would the nursery nurse collect in preparation for bathing a newborn infant? Select all that apply.

• A washcloth

• Thermometer

• Warm tub of water

What should the nurse expect for a full-term newborn's weight during the first few days of life?

• There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns

The parent of a newborn asks why the fetus needed extra red blood cells. How will the nurse respond?

• The fetus was in a low-oxygen environment before birth and needed the extra blood cells to carry the oxygen.""The fetus was in a low-oxygen environment before birth and needed the extra blood cells to carry the oxygen."

The Apgar score is based on which five parameters?

heart rate, muscle tone, reflex irritability, respiratory effort, and color

When instructing a new parent on providing skin care to their newborn, which statement, made by the parent, indicates additional teaching is needed?

"I can use talcum powder to prevent diaper rash."

The nurse is assisting with the admission of a newborn to the nursery. The nurse notes what appears to be bruising on the left upper outer thigh of this dark-skinned newborn. Which documentation should the nurse provide?

• Congenital dermal melanocytosis (slate gray nevi) noted on left upper outer thigh

Which action would be priority for the nurse to complete immediately after the delivery of a 40-week gestation newborn?

Dry the newborn and place it skin-to-skin on the birthing parent.

The nurse is caring for a newborn who was delivered via a planned cesarean birth. The nurse determines the infant requires closer monitoring than a vaginal delivery infant based on which factor?

Excessive fluid in the infant's lungs, making respiratory adaptation more challenging.

The nurse suspects that a newborn is experiencing a drop in its blood sugar. Which symptoms are early signs of hypoglycemia in this client? Select all that apply.

• jitteriness

• irritability

• low body temperature

The student nurse is attending their first cesarean delivery and is asked by the mentor what should be carefully assessed in this infant. After responding "Respiratory status" the student is asked "Why?" What would be the best response?

There is more fluid present in the lungs at birth after a cesarean delivery than after a vaginal delivery.""There is more fluid present in the lungs at birth after a cesarean delivery than after a vaginal delivery."

Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress?

asymmetrical chest movement- short periods of apnea (less than 15 seconds)

The nurse is teaching a prenatal class illustrating the steps that are used to keep families safe. The nurse determines the session is successful when the parents correctly choose which precaution to follow after the birth of their infant?

Check the identification badge of any health care worker before releasing the infant from room

Within three days of birth, a newborn has developed a yellowish tinge that extends from face to mid-chest, is lethargic, and has to be awoken to feed. Which condition does the nurse suspect this infant is manifesting?

Physiologic jaundice.Physiologic jaundice.

The nursing instructor is conducting a teaching session illustrating the basics of feeding newborns. The instructor determines the class is successful after the students correctly choose which disorder as a contraindication to breastfeeding?

galactosemia

A client delivers their newborn and has chosen to formula-feed their baby. They ask the nurse how to keep their breasts from making milk. How would the nurse respond to the client’s question?

• The client needs to understand that they will produce some milk, but wearing a constrictive bra will help dry up the milk supply.

The nurse is conducting a prenatal class on breastfeeding. The nurse determines the class is successful when the young parents correctly choose which time frame is recommended for breastfeeding the infant?

• two years

A nurse is caring for a pregnant client undergoing chemotherapy treatment. Which instruction will a nurse give to this client regarding the ability to breastfeed the newborn?

• Take the chemotherapeutic medication after breastfeeding.Take the chemotherapeutic medication after breastfeeding.

A young couple are discussing how long the birth parent should breastfeed and cannot agree on a time frame. What is the best response from the nurse when they question the nurse about it?

"The recommendation is to use only breast milk for the first 6 months, then add other foods until 12 months."

During a postpartum parenting class, a client reports that they have switched their 6-month-old from formula to cow's milk to save money. Which of the following responses from the nurse would be most appropriate?

• “Cow’s milk should not be used with infants younger than 9 months.”

A client tells the nurse they are unsure whether their baby is getting enough milk when they breastfeed. The nurse's best response would be:

“If your baby appears content between feedings and is wetting diapers, they are getting enough milk.”

A G1 P1 client asks the nurse "Why is my baby losing weight? They dropped 6 oz from yesterday to today. Is my breast milk not good?" Which answer is the best response to this new parent?

A breastfeeding parent, 1-month postpartum, calls the clinic and reports left breast soreness, a temperature of 100.4°F (38°C), and feeling tired all the time. The nurse suspects the client is experiencing which situation after revealing they are still trying to breastfeed on a regular schedule?

mastitis

A new parent is talking with the nurse about breastfeeding. They ask, “How does lactation work?” The best answer by the nurse is:

The newborn sucking on the breast stimulates the pituitary gland causing the release of prolactin and oxytocin. Prolactin causes synthesis and release of breast milk and oxytocin causes contraction of the smooth muscle around the alveoli of the breast.

When educating a client about newborn feedings, what instruction should the nurse give on the proper way to heat a bottle?

• running it under warm water or in a bottle warmer

When asked by a parent to compare the feeding habits of formula-fed and breastfed infants, what is the correct response from the nurse about breastfed infants?

go approximately 3 hours between feedings

A client is planning to use formula for the newborn and asks the nurse how to warm the formula. After teaching the client about ways to warm formula, the nurse determines the teaching was successful based on which client statement?

• "It's best to put the bottle into a bowl of warm water for several minutes."

Choose the correct statement regarding breast milk production.

• Oxytocin is responsible for the let-down reflex, and prolactin stimulates milk production.

A nurse is teaching a new parent about feeding their newborn. The parent tells the nurse that they are afraid that they will either feed their baby too much or not enough. Which information would the nurse include as a sign of hunger in a newborn? Select all that apply.

• restlessness

• tongue thrusting

• smacking lips

Which feeding position should the nurse recommend for a client who has just had a cesarean birth?

side-laying.

During a postpartum parenting class, a client reports that they have switched their 6-month-old from formula to cow's milk to save money. Which of the following responses from the nurse would be most appropriate?

• “Cow’s milk should not be used with infants younger than 6 months.”

The nurse is preparing discharge instructions for a new parent who has been learning to breastfeed. Which response should the nurse prioritize when the client questions their ability to produce enough milk for their infant?

Drink a lot of fluids.Drink a lot of fluids.

When working with a new parent sharing information as to when the newborn is getting hungry, the nurse should include which manifestations? Select all that apply.

• fussiness leading to crying

• increase in restlessness

• mouth movements

A 35-year-old client has just given birth to a healthy newborn during the 43rd week of gestation. What should the nurse expect when assessing the condition of the newborn?

meconium aspiration in utero or at birth

Which condition may cause intrauterine asphyxia? Select all that apply.

• cord compression

• intrauterine growth restriction (IUGR)

• placental abruption (abruptio placentae)

The parent of a preterm infant tells the nurse that they would like to visit their newborn in the neonatal intensive care unit (NICU). Which response by the nurse would be most appropriate?

"Certainly. You will need to wash your hands and gown before you can hold the child,

Following resuscitation, a newborn weighing 1,814 g (4 lb) is admitted to the NICU. The nurse initiates enteral feedings based on which assessment finding?

stabilized respiratory effort- Enteral feedings are initiated when respiratory effort is stabilized. Newborns have periodic breathing with apnea. Cardiac function is not an indicator of readiness for enteral feedings. Even with bowel sounds present, enteral feedings will be delayed if respiratory effort is unstable.

A 20-year-old client gave birth to an infant at 43 weeks' gestation. What might the nurse observe in the newborn during routine assessment?

The newborn may look wrinkled and old at birth.

Due to the client's PROM more than 24 hours prior to arriving to the hospital, the nurse determines the client is at risk for contracting

group B streptococcus and should plan to implement administer intravenous antibiotics

The nursery nurse is providing shift handoff on a newborn documented as small for gestational age. Which clinical manifestations would the nurse expect to communicate about this newborn? Select all that apply.

Poor muscle tone over buttocks

Sunken abdomen

Dry or thin umbilical cord

When examining a neonate, which characteristic would indicate to the nurse that the infant is preterm? Select all that apply.

• absence of sole creases

• covered with vernix caseosa

• extended extremities

A 33-week-gestation infant has just been born. The child's heartbeat is not audible. What is the priority nursing intervention?

• Depression of the sternum with both thumbs 1 to 2 cm at a rate of 100 times per minute- *CPR for newborn