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After delivery, the nurse's assessment reveals a soft, boggy uterus located above the level of the umbilicus. What is the most appropriate nursing intervention?
- A. Notify the physician.
- B. Massage the fundus.
- C. Initiate measures that encourage voiding.
- D. Position the patient flat.
Correct Answer: B
Rationale: A poorly contracted uterus should be massaged until firm to prevent hemorrhage.
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The nurse instructed a postpartum woman about storing and freezing breast milk. What statement by the woman leads the nurse to determine that the teaching was effective?
- A. I can thaw frozen breast milk in the microwave.'
- B. I'll put enough breast milk for one day in a container.'
- C. Breast milk can be stored in glass containers.'
- D. Breast milk can be kept in the refrigerator for up to 3 months.'
Correct Answer: C
Rationale: Breast milk can be safely stored in glass or clear hard plastic containers.
A woman required a cesarean section for safe delivery of her newborn. She is planning to breastfeed and verbalized concern about pain. What is the best suggestion by the nurse?
- A. Consider formula feeding for the first few days.'
- B. Pumping breast milk would be best for now.'
- C. Take pain medication 30 to 40 minutes prior to nursing.'
- D. Use the football hold when breastfeeding.'
Correct Answer: D
Rationale: The football hold is recommended to decrease pressure on the operative site, making breastfeeding more comfortable for a mother post-cesarean section.
Which statement indicates the new mother is breastfeeding correctly?
- A. I will alternate breasts when feeding the baby.'
- B. I keep the baby on a 4-hour feeding schedule.'
- C. I let the baby stay on the first breast only 5 minutes.'
- D. I put only the nipple in the baby's mouth when I am breastfeeding.'
Correct Answer: A
Rationale: Alternating breasts for feeding increases milk production, particularly hindmilk, which has a higher protein and fat content.
In the recovery room, the nurse checks the newly delivered woman's fundus following a cesarean section. How would the nurse proceed with this assessment?
- A. Palpate from the midline to the side of the body.
- B. Palpate from the symphysis to the umbilicus.
- C. Palpate from the side of the uterus to the midline.
- D. Massage the abdomen in a circular motion.
Correct Answer: C
Rationale: The fundus is checked gently by walking the fingers from the side of the uterus to the midline.
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.