Nokea
After delivery of a 9-lb baby the nurse assesses a perineal laceration extending through the muscles of the perineum. The nurse records this as a ___-degree laceration.
Correct Answer: second
Rationale: A second-degree laceration extends through the superficial tissues into the muscles of the perineum.
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The new mother tells the home health nurse that she is concerned about her 5-day-old infant's hard dried umbilical stump. What time frame should the nurse give the mother for the umbilical stump to fall off?
Correct Answer: 10 to 14 days
Rationale: The umbilical stump will turn brownish black and fall off within 10 to 14 days after birth.
What is the appropriate way to assess the fundus of the postpartum patient?
- A. Using the side of one hand moving down from the umbilicus
- B. Using one hand over the lower segment of the uterus
- C. Using one hand pushing upward from the lower uterus
- D. Using one hand on the lower uterine segment while the other hand locates the fundus of the uterus
Correct Answer: D
Rationale: The proper way to assess the fundus of a mother who has just given birth is by placing one hand on the lower uterine segment while the other hand locates the fundus of the uterus.
A mother delivered her baby at midnight and it is now 9 a.m. She wants to sleep and asks the nurse to take care of the baby. What is this considered?
- A. Fatigue from labor
- B. Normal "taking in" response
- C. Abnormal "taking in" response
- D. Risk for altered maternal-infant bonding
Correct Answer: B
Rationale: Her primary focus will be on her own needs such as sleep ("taking in" stage).
The nurse identifies that the newborn is jaundiced within the first 24 hours of birth with jaundice occurring over bony prominences of the face and the mucous membrane. What type of jaundice does this represent?
- A. Physiologic
- B. Normal
- C. Pathologic
- D. Transitory
Correct Answer: C
Rationale: Jaundice that appears within the first 48 hours of life is termed pathologic jaundice and is abnormal. Pathologic jaundice indicates excessive red blood cell destruction and it should be reported. Jaundice that appears after the first 48 hours of life is known as physiologic jaundice and is considered normal.
Which of the following measures could help prevent infant abduction?
- A. Only transport infants by carrying them.
- B. Require staff members to wear appropriate identification badges.
- C. Respond immediately when an alarm sounds.
- D. Never leave infants unattended at any time.
- E. Take all the infants to their mothers at the same time.
Correct Answer: B,C,D
Rationale: Staff members should always wear appropriate ID badges and should respond immediately when an alarm sounds. Infants should never be left unattended. Infants should always be transported in their cribs, never by carrying them. The nurse should transport only one infant at a time.