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Although the nurse has massaged the uterus every 15 minutes, it remains flaccid, and the patient continues to pass large clots. What does the nurse recognize these signs indicate?
- A. Uterine atony
- B. Uterine dystocia
- C. Uterine hypoplasia
- D. Uterine dysfunction
Correct Answer: A
Rationale: Atony describes a lack of normal muscle tone. If the uterus is atonic, then muscle fibers are flaccid and will not compress bleeding vessels.
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What will the nurse's instructions for a new mother to care for the infant's umbilical cord include?
- A. Keeping the area covered with a sterile dressing
- B. Dressing the stump with antibiotic ointment at every diaper change
- C. Fastening the diaper low to allow for air circulation
- D. Giving the newborn a daily tub bath until the cord falls off
Correct Answer: C
Rationale: Diaper placement below the umbilical stump allows for drying by air circulation.
A new mother states her preference to formula feed her newborn. What will the nurse planning discharge instructions tell her to help suppress lactation and promote comfort?
- A. Wear a well-fitting bra continuously for several days.
- B. Stand in a warm shower, letting the water spray over the breasts.
- C. Express small amounts of milk from the breasts several times a day.
- D. Massage the breasts when they ache.
Correct Answer: A
Rationale: When a mother does not wish to breastfeed, a snug bra worn around the clock can help alleviate discomfort from engorgement.
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.
On the second postpartum day, a mother bathed her newborn for the first time. She tells the nurse, 'I don't think I did it right.' What postpartum psychological stage is this woman most likely in based on this comment?
- A. Taking in
- B. Taking hold
- C. Letting go
- D. Settling down
Correct Answer: B
Rationale: In phase 2, taking hold, the mother begins to initiate action and becomes interested in caring for the infant. In doing so, she may become critical of her performance.
While instructing a new mother on formula preparations, the nurse would include what types? (Select all that apply.)
- A. Ready-to-feed formula
- B. Concentrated liquid formula
- C. Powdered formula
- D. Cow's milk
- E. Canned evaporated milk
Correct Answer: A,B,C
Rationale: Formula choices are ready-to-use, concentrated liquid formula that will be diluted according to the infant's needs, and powdered formula that is mixed as needed. Cow's milk and canned evaporated milk are unsuitable, because they are nutritionally inadequate and stress the kidneys.