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The mother notes that her baby has a 'bulge' on the back of one side of the head. She calls the nurse into the room to ask what the bulge is. The nurse notes that the bulge covers the right parietal bone but does not cross the suture lines. The nurse explains to the mother that the bulge results from which of the following?
- A. Molding of the baby's skull so that the baby could fit through her pelvis.
- B. Swelling of the tissues of the baby's head from the pressure of her pushing.
- C. The position that the baby took in her pelvis during the last trimester of her pregnancy.
- D. Small blood vessels that broke under the baby's scalp during birth.
Correct Answer: A
Rationale: Molding occurs due to passage through the birth canal.
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A full-term newborn was just born. Which nursing intervention is important for the nurse to perform first?
- A. Remove wet blankets.
- B. Assess Apgar score.
- C. Insert eye prophylaxis.
- D. Elicit the Moro reflex.
Correct Answer: B
Rationale: Assessing the Apgar score is a priority immediately after birth to evaluate the newborn's overall condition.
Which measure is optimal in order to prevent abdominal distention following a cesarean birth?
- A. Rectal suppositories
- B. Carbonated beverages
- C. Early and frequent ambulation
- D. Tightening and relaxing abdominal muscles
Correct Answer: C
Rationale: The correct answer is C: Early and frequent ambulation. This measure is optimal to prevent abdominal distention following a cesarean birth because it helps promote bowel motility and gas expulsion. Ambulation stimulates peristalsis, preventing gas accumulation and reducing the risk of distention. Rectal suppositories (A) may help with constipation but do not address the root cause of distention. Carbonated beverages (B) can exacerbate bloating and gas production. Tightening and relaxing abdominal muscles (D) may provide some relief but are not as effective as promoting ambulation for preventing abdominal distention.
A client is preparing to breastfeed her newborn son in the cross-cradle position. Which of the following actions should the woman make?
- A. Place a pillow in her lap.
- B. Position the head of the baby in her elbow.
- C. Put the baby on his back.
- D. Move the breast toward the mouth of the baby.
Correct Answer: A
Rationale: A pillow supports the baby and reduces strain.
A client just delivered the placenta pictured below. The nurse will document that the woman delivered which of following placentas?
- A. Circumvallate placenta.
- B. Succenturiate placenta.
- C. Placenta with velamentous cord insertion.
- D. Battledore placenta.
Correct Answer: B
Rationale: Succenturiate placenta has accessory lobes.
The person with a cesarean birth has additional nursing concerns beyond those of a person with a vaginal birth. What concern should the nurse anticipate for the cesarean birth?
- A. increased risk for DVT
- B. faster recovery
- C. less use of pain medication
- D. less risk for infection
Correct Answer: A
Rationale: The correct answer is A: increased risk for DVT. Cesarean birth increases the risk of Deep Vein Thrombosis (DVT) due to reduced mobility and potential blood clot formation. This is a critical concern as DVT can lead to serious complications like pulmonary embolism. Choices B and C are incorrect as cesarean birth typically results in longer recovery time and increased need for pain medication compared to vaginal birth. Choice D is incorrect as cesarean birth poses a higher risk of infection due to the surgical incision.