Nokea
A client just delivered the placenta pictured below. For which of the following complications should the nurse carefully observe the woman?
- A. Endometrial ischemia.
- B. Postpartum hemorrhage.
- C. Prolapsed uterus.
- D. Vaginal hematoma.
Correct Answer: B
Rationale: Abnormal placentas increase hemorrhage risk.
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A breastfeeding mother who is 2 weeks postpartum is informed by her pediatrician that her 4-year-old has chickenpox (varicella). The mother calls the nursery nurse because she is concerned about having the baby in contact with the sick sibling. The mother had chickenpox as a child. Which of the following responses by the nurse is appropriate?
- A. The baby received passive immunity through the placenta
- B. plus the breast milk will also be protective.
- C. The baby should stay with relatives until the ill sibling recovers from the episode of chickenpox.
- D. Chickenpox is transmitted by contact route so careful hand washing should prevent transmission.
Correct Answer: A
Rationale: Maternal antibodies protect the baby, and breast milk enhances immunity.
The nurse reviews postpartum discharge instructions regarding sexual health. What information is important to review?
- A. Place nothing in the vagina for 4–6 weeks.
- B. Pregnancy cannot occur until 3 months after birth.
- C. Sexual intercourse can resume after discharge from the facility.
- D. Postpartum persons do not have a need for sexual intimacy.
Correct Answer: A
Rationale: Rationale for Correct Answer (A):
- A: Correct because postpartum women should avoid placing anything in the vagina to prevent infection and allow healing.
- B: Incorrect because ovulation can occur before the first postpartum period.
- C: Incorrect because resuming sexual intercourse should be based on individual healing and comfort, not just discharge.
- D: Incorrect because sexual intimacy is a normal part of relationships and should be discussed postpartum for emotional well-being.
The nurse is performing a postpartum assessment on a client who delivered 4 hours ago. The nurse notes a firm uterus at the umbilicus with heavy lochial flow. Which of the following nursing actions is appropriate?
- A. Massage the uterus.
- B. Notify the obstetrician.
- C. Administer an oxytocic as ordered.
- D. Assist the client to the bathroom.
Correct Answer: C
Rationale: Oxytocics help control uterine atony and bleeding.
The nurse does not hear the baby swallow when suckling even though the baby appears to be latched properly to the breast. Which of the following situations may be the reason for this observation?
- A. The mother reports a pain level of 4 on a 5-point scale.
- B. The baby has been suckling for over 10 minutes.
- C. The mother uses the cross-cradle hold while feeding.
- D. The baby lies with the chin touching the under part of the breast.
Correct Answer: D
Rationale: Proper latch involves the chin touching the breast for efficient milk transfer.
A neonate is being admitted to the well-baby nursery. Which of the following findings should be reported to the neonatologist?
- A. Umbilical cord with three vessels.
- B. Diamond-shaped anterior fontanelle.
- C. Cryptorchidism.
- D. Café au lait spot.
Correct Answer: C
Rationale: Cryptorchidism (undescended testes) requires medical evaluation.