Nokea
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.
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What is the first secretion produced by the breast?
- A. Prolactin
- B. Colostrum
- C. False milk
- D. Whey
Correct Answer: B
Rationale: The first secretion to be produced by the breast is colostrum.
What is the term for the cream cheese-like substance that protects the infant's skin from amniotic fluid?
- A. Lanugo
- B. Meconium
- C. Desquamation
- D. Vernix caseosa
Correct Answer: D
Rationale: At birth, the skin is covered with a yellowish-white cream cheese-like substance called vernix caseosa.
What should be included in a teaching plan regarding breast engorgement?
- A. It typically occurs on the first postpartum day.
- B. It is usually first observed in the axillary region.
- C. It occurs only in women who are not breastfeeding.
- D. It occurs near the nipple on the third postpartum day.
Correct Answer: B
Rationale: Filling of the breast with milk (engorgement) usually begins in the axillary region on the third postpartum day when the milk comes in. It occurs regardless of whether the mother is breastfeeding or bottle-feeding.
Which of the following would be considered a normal assessment finding in a 1-day postpartum patient?
- A. Pinkish to brown lochia
- B. Voiding frequently 50 to 75 mL of urine
- C. Complaining of "after pains"
- D. Fundus 1 cm above the umbilicus
Correct Answer: C
Rationale: The common discomfort of after pains is a normal assessment finding at 1-day postpartum. The normal discharge 1-day postpartum would be lochia rubra, which is made up of mostly blood. The fundus would be palpated at the level of the umbilicus. Frequent voiding would be considered abnormal.
Following delivery of the newborn which nursing intervention should be carried out immediately?
- A. Weigh the infant.
- B. Warm the infant.
- C. Bathe the infant.
- D. Inoculate the infant.
Correct Answer: B
Rationale: Maintenance of body temperature is the primary concern when caring for the newborn. The infant will also be weighed, bathed, and inoculated, but those measures are not the primary concern.