Nokea
A female African American baby has been admitted into the nursery. Which of the following physiological findings would the nurse assess as normal?Select one that doesn't apply
- A. Purple-colored patches on the buttocks and torso.
- B. Bilateral whitish discharge from the breasts.
- C. Bloody discharge from the vagina.
- D. Sharply demarcated dark red area on the face.
Correct Answer: D
Rationale: Transient phenomena such as mongolian spots, witch's milk, and pseudo-menstruation are normal in newborns.
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The nurse should expect to observe which behavior in a 3-week-multigravid postpartum client with postpartum depression?
- A. Feelings of infanticide.
- B. Difficulty with breastfeeding latch.
- C. Feelings of failure as a mother.
- D. Concerns about sibling jealousy.
Correct Answer: C
Rationale: Postpartum depression often manifests as feelings of inadequacy.
Which measure is optimal in order to prevent abdominal distention following a cesarean birth?
- A. Rectal suppositories
- B. Carbonated beverages
- C. Early and frequent ambulation
- D. Tightening and relaxing abdominal muscles
Correct Answer: C
Rationale: The correct answer is C: Early and frequent ambulation. This measure is optimal to prevent abdominal distention following a cesarean birth because it helps promote bowel motility and gas expulsion. Ambulation stimulates peristalsis, preventing gas accumulation and reducing the risk of distention. Rectal suppositories (A) may help with constipation but do not address the root cause of distention. Carbonated beverages (B) can exacerbate bloating and gas production. Tightening and relaxing abdominal muscles (D) may provide some relief but are not as effective as promoting ambulation for preventing abdominal distention.
What type of lochia is bright to dark red and occurs on days 1–3 postpartum?
- A. rubra
- B. serosa
- C. placental
- D. alba
Correct Answer: A
Rationale: The correct answer is A: rubra. Lochia rubra is bright to dark red, typically occurring on days 1-3 postpartum. This is due to the presence of blood and decidual tissue. Serosa (B) is pinkish-brown and occurs around days 4-10, representing a mix of blood and mucus. Placental (C) is typically expelled within 30 minutes postpartum and consists of dark red blood. Alba (D) is whitish-yellow, appearing around day 10 and lasting up to 6 weeks, indicating the final stage of lochia consisting of leukocytes and decidual tissue.
A postoperative cesarean client, who was diagnosed with severe preeclampsia in labor and delivery, is transferred to the postpartum unit. The nurse is reviewing the client's doctor's orders. Which of the following medications that were ordered by the doctor should the nurse question?
- A. Methergine (methylergonovine).
- B. Magnesium sulfate.
- C. Advil (ibuprofen).
- D. Morphine sulfate.
Correct Answer: B
Rationale: Magnesium sulfate is contraindicated post-delivery.
The nurse is assessing a neonate in the newborn nursery. Which of the following findings in a newborn should be reported to the neonatologist?
- A. The eyes cross and uncross when they are open.
- B. The ears are positioned in alignment with the inner and outer canthus of the eyes.
- C. Axillae and femoral folds of the baby are covered with a white cheesy substance.
- D. The nostrils flare whenever the baby inhales.
Correct Answer: D
Rationale: Nostril flaring indicates respiratory distress.