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Chapter 09 the family after birth
Maternity/Peds (PRN06900)
McFatter Technical College
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Chapter 09: The Family After Birth
MULTIPLE CHOICE
- The nurse is assessing a newborn. What sign of hypoglycemia does the nurse record? a. Increased nasal mucus b. Increased temperature c. Active muscle movements d. High-pitched cry ANS: D There are many signs of hypoglycemia in the newborn. One is a high-pitched cry.
DIF: Cognitive Level: Comprehension REF: Page 219 OBJ: 9 TOP: Signs of Hypoglycemia KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk
- What would the nurse expect to find when assessing the fundus of the uterus immediately after delivery? a. Well-contracted with its upper border at or just below the umbilicus b. Well-contracted with its upper border three or four fingerbreadths above the umbilicus c. Relaxed with its upper border level with the umbilicus d. Relaxed with its upper border two or three fingerbreadths below the umbilicus ANS: A Immediately after the placenta is expelled, the uterine fundus can be felt as a firm mass, about the size of a grapefruit, at the level of the umbilicus.
DIF: Cognitive Level: Comprehension REF: Page 200 OBJ: 2 TOP: Fundus Assessment KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- What statement made by a new mother indicates she needs additional information about breastfeeding? a. I let the baby nurse 10 to 15 minutes on the first breast and then switch to the other breast. b. The baby needs to nurse at least 5 minutes on the breast to get the hindmilk. c. The baby has been nursing every 2 to 3 hours. d. If the baby gets fussy between feedings, I give her a bottle of water. ANS: D Supplemental feedings of formula or water should not be offered to a healthy newborn who is breastfeeding.
DIF: Cognitive Level: Comprehension REF: Page 223- OBJ: 14 TOP: BreastfeedingSupplemental Feedings KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- After delivery, the nurses assessment reveals a soft, boggy uterus located above the level of the umbilicus. What is the most appropriate nursing intervention? a. Notify the physician. b. Massage the fundus. c. Initiate measures that encourage voiding. d. Position the patient flat. ANS: B A poorly contracted uterus should be massaged until firm to prevent hemorrhage.
DIF: Cognitive Level: Application REF: Page 202 OBJ: 9 TOP: Boggy Uterus KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- What type of lochia will the nurse assess initially after delivery? a. Serosa b. Rubra c. Alba d. Vaginalis ANS: B The initial vaginal discharge after delivery is called lochia rubra. It is red and moderately heavy. Lochia rubra lasts for up to 3 days postpartum.
DIF: Cognitive Level: Knowledge REF: Page 202 OBJ: 4 TOP: Lochia Rubra KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- A woman will be discharged 48 hours after a vaginal delivery. When planning discharge teaching, the nurse would include what information about lochia? a. Lochia should disappear 2 to 4 weeks postpartum. b. It is normal for the lochia to have a slightly foul odor. c. A change in lochia from pink to bright red should be reported. d. A decrease in flow will be noticed with ambulation and activity. ANS: C A return to bright red lochia rubra may indicate a late postpartum hemorrhage and must be reported.
DIF: Cognitive Level: Application REF: Page 203 OBJ: 18 TOP: Hemorrhage KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- What instruction should the nurse teach the postpartum woman about perineal self-care? a. Perform perineal self-care at least twice a day. b. Cleanse with warm water in a squeeze bottle from front to back.
day over her prepregnancy diet.
DIF: Cognitive Level: Comprehension REF: Page 230 OBJ: 15 TOP: BreastfeedingMaternal Nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- A woman asks about resumption of her menstrual cycle after childbirth. What should the nurse respond? a. A woman will not ovulate in the absence of menstrual flow. b. Most nonlactating women resume menstruation about 2 months postpartum. c. Generally, a woman does not ovulate in the first few cycles after childbirth. d. The return of menstruation is delayed when a woman does not breastfeed. ANS: B Menstrual periods resume in about 6 to 8 weeks if the woman is not breastfeeding.
DIF: Cognitive Level: Comprehension REF: Page 205 OBJ: 4 TOP: Return of Menses KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- In what situation will the physician order RhoGAM? a. An unsensitized Rh-negative mother has an Rh-positive infant. b. An Rh-negative mother becomes sensitized. c. A sensitized infant has a rising bilirubin level. d. An unsensitized infant exhibits no outward signs. ANS: A The Rh-negative woman should receive RhoGAM within 72 hours after the birth of an Rh- positive infant.
DIF: Cognitive Level: Analysis REF: Page 209 OBJ: 4 TOP: RhoGAM KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
- After birth, the nurse quickly dries and wraps the newborn in a blanket. How does this action prevent heat loss?
a. Conduction b. Radiation c. Evaporation d. Convection ANS: C Newborns lose heat quickly after birth as fluid evaporates from their bodies.
DIF: Cognitive Level: Comprehension REF: Page 216, Table 9- OBJ: 2 TOP: Thermoregulation
KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- What will the nurses instructions for a new mother to care for the infants umbilical cord include? a. Keeping the area covered with a sterile dressing b. Dressing the stump with antibiotic ointment at every diaper change c. Fastening the diaper low to allow for air circulation d. Giving the newborn a daily tub bath until the cord falls off ANS: C Diaper placement below the umbilical stump allows for drying by air circulation.
DIF: Cognitive Level: Application REF: Page 218-219, Skill 9- OBJ: 2 TOP: Umbilical Cord Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
- A new mother states her preference to formula feed her newborn. What will the nurse planning discharge instructions tell her to help suppress lactation and promote comfort? a. Wear a well-fitting bra continuously for several days. b. Stand in a warm shower, letting the water spray over the breasts. c. Express small amounts of milk from the breasts several times a day. d. Massage the breasts when they ache. ANS: A When a mother does not wish to breastfeed, a snug bra worn around the clock can help alleviate discomfort from engorgement.
DIF: Cognitive Level: Application REF: Page 230 OBJ: 18 TOP: Suppression of Lactation KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
- On the second postpartum day, a mother bathed her newborn for the first time. She tells the nurse, I dont think I did it right. What postpartum psychological stage is this woman most likely in based on this comment? a. Taking in b. Taking hold c. Letting go d. Settling down ANS: B In phase 2, taking hold, the mother begins to initiate action and becomes interested in caring for the infant. In doing so, she may become critical of her performance.
DIF: Cognitive Level: Application REF: Page 209 OBJ: 5 TOP: Postpartum Cesarean Assessment KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
- The nurse instructed a postpartum woman about storing and freezing breast milk. What statement by the woman leads the nurse to determine that the teaching was effective? a. I can thaw frozen breast milk in the microwave. b. Ill put enough breast milk for one day in a container. c. Breast milk can be stored in glass containers. d. Breast milk can be kept in the refrigerator for up to 3 months. ANS: C Breast milk can be safely stored in glass or clear hard plastic containers.
DIF: Cognitive Level: Comprehension REF: Page 229 OBJ: 14 TOP: Storing Breast Milk KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
- What should the nurse implement for security purposes when bringing the infant from the nursery to the mother? a. Ask, Is this your band number? b. Confirm room number of mother. c. Ask the mother to identify herself verbally. d. Check the band number of the infant with that of the mother. ANS: D The nurse should check the band number of the infant with that of the mother by asking the mother to verbally read the number.
DIF: Cognitive Level: Application REF: Page 216- OBJ: 8 TOP: Security Identification Procedure KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
- Below what blood glucose level is the newborn considered hypoglycemic? a. Below 70 mg/dL b. Below 60 mg/dL c. Below 50 mg/dL d. Below 40 mg/dL ANS: D A blood glucose level of less than 40 mg/dL is considered hypoglycemic. If the screening sample is below 40 mg/dL, a venous sample will be drawn. After the blood has been drawn, the infant should be fed to prevent a further drop.
DIF: Cognitive Level: Comprehension REF: Page 219 OBJ: 8 TOP: Hypoglycemia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk
- The nurse is caring for a woman of Middle Eastern descent on the first postpartum day. Education is provided regarding instruction on use of a sitz bath. What documentation best indicates that the woman has understood the provided instruction? a. Patient correctly performed return demonstration. b. Patient indicated understanding by nodding head with instruction. c. Patient verbalizes I understand. d. Family member indicates patient understands procedure. ANS: A The nurse may need an interpreter to understand and provide optimal care to the woman and her family. If possible, when discussing sensitive information the interpreter should not be a family member, who might interpret selectively. The interpreter should not be of a group that is in social or religious conflict with the patient and her family, an issue that might arise in many Middle Eastern cultures. It is also important to remember that an affirmative nod from the woman may be a sign of courtesy to the nurse rather than a sign of understanding or agreement.
DIF: Cognitive Level: Application REF: Page 200 OBJ: 3 TOP: Cultural Influences KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Cultural Awareness
- A woman has given birth to an unresponsive newborn that NICU staff are attempting to revive. The patient and her husband are grief stricken and request the child be baptized immediately. What is the nurses most appropriate action? a. Contact the hospital chaplain. b. Request the couples clergy. c. Baptize the newborn. d. Ask the physician to baptize the newborn. ANS: C If the condition of a newborn is poor, the parents may wish to have a baptism performed. The minister or priest is notified. However this is an emergency, so the nurse may perform the baptism by pouring water on the infants forehead while saying, I baptize you in the name of the Father, and of the Son, and of the Holy
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
- The nurse is giving a shower to a patient who had a cesarean section 2 days previously. What interventions should be included before, during, and after the shower? (Select all that apply.) a. Leave abdominal dressing open to air. b. Position patient with back to water stream. c. Cover infusion site with rubber glove. d. Provide a shower chair. e. Confirm ambulation ability. ANS: B, C, D, E The patient should be evaluated for ambulatory ability, and the abdominal dressing and infusion site should be covered with a waterproof cover. The patient should be provided a shower chair and positioned with her back to the water stream.
DIF: Cognitive Level: Application REF: Page 209- OBJ: 5 TOP: Postpartum Shower KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
- What postpartum exercises should the nurse teach a patient who had a vaginal delivery yesterday? (Select all that apply.) a. Abdominal tighteners b. Head lift c. Pelvic tilt d. Kegel exercises e. Leg lifts ANS: A, B, C, D Exercises for postpartum involution such as abdominal tighteners, head lifts, pelvic tilts, and Kegel exercises are acceptable. Leg lifts are too strenuous early in the postpartum period.
DIF: Cognitive Level: Comprehension REF: Page 208 OBJ: 18 TOP: Postpartum Exercises KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- While instructing a new mother on formula preparations, the nurse would include what types? (Select all that apply.) a. Ready-to-feed formula b. Concentrated liquid formula c. Powdered formula d. Cows milk
e. Canned evaporated milk
ANS: A, B, C Formula choices are ready-to-use, concentrated liquid formula that will be diluted according to the infants needs and powdered formula that is mixed as needed. Cows milk and canned evaporated milk are unsuitable because they are nutritionally inadequate and stress the kidneys.
DIF: Cognitive Level: Comprehension REF: Page 231 OBJ: 17 TOP: Formula Choices KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
- The nurse is instructing a woman at 6 months postpartum on weaning her infant from breastfeeding. What interventions will the nurse suggest? (Select all that apply.) a. Omit newborns favorite feeding first. b. Eliminate one feeding at a time. c. Expect the need for comfort feeding. d. Formula will need to be provided to substitute for feeding. e. Pump breasts in place of eliminated feeding. ANS: B, C, D When weaning a newborn from breastfeeding, the mother should eliminate the favorite feeding last. One feeding should be eliminated at a time, and the need for comfort feeding should be expected. In younger infants formula will need to be substituted. The mother should not be instructed to pump in place of eliminated feeding or the breasts will continue to produce milk.
DIF: Cognitive Level: Comprehension REF: Page 230 OBJ: 16 TOP: Weaning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
COMPLETION
- The nurse assesses a 6-inch stain of lochia rubra on a pad that was worn for 2 hours. The nurse would document this as a(n) ________________ amount of lochia.
ANS: moderate
A 6-inch stain on a pad worn for 2 hours is regarded as a moderate amount of lochia discharge.
DIF: Cognitive Level: Application REF: Page 202, Skill 9-
ANS:
Involution
Involution refers to changes that the reproductive organs, particularly the uterus, undergo after birth to return to their prepregnancy size and condition.
DIF: Cognitive Level: Knowledge REF: Page 200 OBJ: 1 TOP: Puerperium KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation
Chapter 09 the family after birth
Course: Maternity/Peds (PRN06900)
University: McFatter Technical College
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