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A client who is 2 days postpartum has a saturated perineal pad with bright red lochia containing small clots. What should the nurse document in the client's medical record?
- A. Moderate lochia rubra
- B. Excessive lochia serosa
- C. Light lochia rubra
- D. Scant lochia serosa
Correct Answer: A
Rationale: The correct answer is A: Moderate lochia rubra. This indicates normal postpartum bleeding 2 days after delivery. Bright red lochia with small clots is expected at this stage. Excessive lochia serosa (B) and scant lochia serosa (D) are not appropriate as serosa typically appears after the first few days postpartum. Light lochia rubra (C) does not accurately describe the amount of bleeding observed in this scenario.
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When assisting a client with breastfeeding, which of the following reflexes will promote the newborn to latch?
- A. Babinski
- B. Rooting
- C. Moro
- D. Stepping
Correct Answer: B
Rationale: The correct answer is B: Rooting. This reflex helps the newborn turn their head towards a stimulus, such as the mother's nipple, facilitating latching during breastfeeding. Babinski (A) is a reflex related to the sole of the foot, Moro (C) is a startle reflex, and Stepping (D) involves movements resembling walking. These reflexes do not directly support the latch during breastfeeding. Rooting reflex is the most relevant and essential reflex for successful breastfeeding initiation.
When reinforcing discharge teaching to the parents of a newborn regarding circumcision care, which statement made by a parent indicates an understanding of the teaching?
- A. The circumcision will heal within a couple of days.
- B. I should not remove the yellow mucus that will form.
- C. I will clean the penis with each diaper change.
- D. I will give him a tub bath within a couple of days.
Correct Answer: C
Rationale: The correct answer is C. Cleaning the penis with each diaper change is crucial for proper circumcision care to prevent infection. This statement shows understanding of the teaching as it emphasizes the importance of keeping the area clean.
A: The circumcision healing within a couple of days is incorrect as it usually takes about 1-2 weeks.
B: Not removing the yellow mucus can lead to infection, so this is an incorrect statement.
D: Giving a tub bath within a couple of days can increase the risk of infection, so this statement is incorrect.
During the third trimester of pregnancy, which of the following findings should a nurse recognize as an expected physiologic change?
- A. Gradual lordosis
- B. Increased abdominal muscle tone
- C. Posterior neck flexion
- D. Decreased mobility of pelvic joints
Correct Answer: A
Rationale: The correct answer is A: Gradual lordosis. During the third trimester, the growing uterus shifts the center of gravity forward, leading to an increased lumbar curvature known as lordosis. This change helps maintain balance and support the extra weight. Increased abdominal muscle tone (B) is not an expected finding as abdominal muscles tend to stretch and weaken during pregnancy. Posterior neck flexion (C) is not a common physiologic change during the third trimester. Decreased mobility of pelvic joints (D) is incorrect as hormonal changes during pregnancy actually increase flexibility in the pelvic joints to prepare for childbirth.
When reinforcing teaching with a group of new parents about proper techniques for bottle feeding, which of the following instructions should be provided?
- A. Burp the newborn at the end of the feeding
- B. Hold the newborn close in a supine position
- C. Keep the nipple full of formula throughout the feeding
- D. Refrigerate any unused formula
Correct Answer: C
Rationale: Rationale:
C is correct because keeping the nipple full of formula throughout the feeding helps prevent the baby from swallowing air, reducing the risk of gas and colic. A is incorrect because burping should be done mid-feeding. B is incorrect because newborns should be held in an upright position while feeding to prevent choking. D is incorrect because unused formula should be discarded within 1-2 hours, not refrigerated.
A healthcare provider is assisting with the care of a newborn immediately following birth. Which of the following nursing interventions is the highest priority?
- A. Initiating breastfeeding
- B. Performing the initial bath
- C. Giving a vitamin K injection
- D. Covering the newborn's head with a cap
Correct Answer: D
Rationale: The correct answer is D: Covering the newborn's head with a cap. This is the highest priority as newborns are at risk for heat loss due to their large head surface area. By covering the newborn's head with a cap, heat loss can be minimized, helping to maintain the baby's body temperature. This is crucial for the newborn's overall well-being and to prevent complications such as hypothermia.
Initiating breastfeeding (A) is important for newborn nutrition but can be delayed slightly without immediate harm. Performing the initial bath (B) can also wait as it is not as urgent as maintaining the newborn's temperature. Giving a vitamin K injection (C) is important for blood clotting but can be done after ensuring the baby's temperature is stable.