Nokea
A postpartum woman is not immune to rubella. What will the nurse expect?
- A. The rubella virus vaccine should be administered before discharge.
- B. The woman should receive the rubella virus vaccine at her 6-week postpartum checkup.
- C. The woman should be instructed not to get pregnant until she receives the rubella vaccine.
- D. No intervention is indicated at this time because the woman is not at risk for rubella.
Correct Answer: A
Rationale: The woman who is not immune to rubella is immunized in the immediate postpartum period, because there is no danger of her being pregnant.
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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.'
Correct Answer: D
Rationale: Supplemental feedings of formula or water should not be offered to a healthy newborn who is breastfeeding.
A new mother has decided not to breastfeed her newborn. What information will the nurse include when planning to teach the mother about formula feeding?
- A. Positioning the bottle so that the nipple is full of formula during the entire feeding
- B. Heating the infant formula in a microwave
- C. Burping the infant after 4 ounces and again when the bottle is empty
- D. Propping a bottle for a feeding
Correct Answer: A
Rationale: The nipple of the bottle should be kept full of formula to reduce the amount of air the infant swallows.
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.
Correct Answer: D
Rationale: The nurse should check the band number of the infant with that of the mother by asking the mother to verbally read the number.
Which assessments would lead the nurse to determine the gestational age of the infant as preterm? (Select all that apply.)
- A. Thin, transparent skin
- B. Vernix only in the body creases
- C. Folded ear springs back slowly
- D. Breast tissue under the nipple
- E. Creases over entire sole
Correct Answer: A,C
Rationale: The only signs of preterm are the thin skin and the slowly responding ear.
What type of lochia will the nurse assess initially after delivery?
- A. Serosa
- B. Rubra
- C. Alba
- D. Vaginalis
Correct Answer: B
Rationale: 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.