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A new mother had spinal anesthesia during a cesarean delivery. She now has a desire to void and can wiggle her toes. What should be the nurse's response when the mother asks to go the bathroom?
- A. Assess her blood pressure.
- B. Obtain a wheelchair.
- C. Palpate her bladder.
- D. Put slippers on her feet.
Correct Answer: D
Rationale: The nurse should check that the mother is wearing slippers to ensure better footing. If the mother has a desire to void and can move her toes, there is no need for her to remain bedridden.
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Where would acrocyanosis be assessed on a newborn?
- A. Circumoral area
- B. Brow
- C. Feet
- D. Mucous membrane
Correct Answer: C
Rationale: Acrocyanosis is the slightly blue appearance of the hands and feet that is caused by poor circulation. It can last for 7 to 10 days in the newborn.
What is the name of the vaginal discharge that occurs immediately following delivery?
- A. Lochia serosa
- B. Lochia rubra
- C. Lochia palatine
- D. Lochia alba
Correct Answer: B
Rationale: The vaginal discharge that occurs immediately following discharge is known as lochia rubra and is made up mostly of blood. As the placenta heals, the draining turns pink to dark brown in color and is known as lochia serosa. After about 7 days, the discharge turns slight yellow to white and is called lochia alba.
Before initially feeding an infant what reflex should the nurse assess?
- A. Moro reflex
- B. Rooting reflex
- C. Babinski reflex
- D. Swallow reflex
Correct Answer: D
Rationale: The nurse should verify that the infant is able to swallow normally before feeding.
Which statement would be a correct description of colostrum?
- A. Slightly yellow and low in protein
- B. Slightly yellow and provides antibodies
- C. Creamy and high in fat and protein
- D. Colorless and high in fat and carbohydrates
Correct Answer: B
Rationale: Colostrum is slightly yellow in color and is rich in antibodies.
The postpartum mother with a third degree laceration tells the nurse she is afraid to have a bowel movement because of her painful episiotomy. What should the nurse do?
- A. Offer a suppository or enema.
- B. Encourage ambulation.
- C. Offer stool softeners as prescribed.
- D. Offer pain medication before defecating.
Correct Answer: C
Rationale: Stool softeners are available to ease the pain of defecation caused by hemorrhoids and birth trauma. Suppositories or enemas are contraindicated in mothers with third or fourth degree lacerations. Pain medications can often cause constipation. Ambulation may aid in defecation, but will not soften the stool.