Nokea
In what situation will the physician order RhoGAM?
- A. An unsensitized Rh-negative mother has an Rh-positive infant.
- B. An Rh-negative mother becomes sensitized.
- C. A sensitized infant has a rising bilirubin level.
- D. An unsensitized infant exhibits no outward signs.
Correct Answer: A
Rationale: The Rh-negative woman should receive RhoGAM within 72 hours after the birth of an Rh-positive infant.
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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.
The nurse is giving a shower to a patient who had a cesarean section 2 days previously. What interventions should be included before, during, and after the shower? (Select all that apply.)
- A. Leave abdominal dressing open to air.
- B. Position patient with back to water stream.
- C. Cover infusion site with rubber glove.
- D. Provide a shower chair.
- E. Confirm ambulation ability.
Correct Answer: B,C,D,E
Rationale: The patient should be evaluated for ambulatory ability, and the abdominal dressing and infusion site should be covered with a waterproof cover. The patient should be provided a shower chair and positioned with her back to the water stream.
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.
What instruction should the nurse teach the postpartum woman about perineal self-care?
- A. Perform perineal self-care at least twice a day.
- B. Cleanse with warm water in a squeeze bottle from front to back.
- C. Remove perineal pads from the rectal area toward the vagina.
- D. Use cool water to decrease edema of the perineum.
Correct Answer: B
Rationale: Cleansing from front to back prevents contamination from the rectal area.
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.