Nokea
The nurse describes the return of the postpartum patient's uterus to a pregravid state as ___.
Correct Answer: involution
Rationale: Involution is the decrease in size of the uterus to a prepregnant state.
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What is the name of the vaginal discharge that occurs immediately following delivery?
- A. Lochia serosa
- B. Lochia rubra
- C. Lochia palatine
- D. Lochia alba
Correct Answer: B
Rationale: The vaginal discharge that occurs immediately following discharge is known as lochia rubra and is made up mostly of blood. As the placenta heals, the draining turns pink to dark brown in color and is known as lochia serosa. After about 7 days, the discharge turns slight yellow to white and is called lochia alba.
When is breast engorgement most likely to occur?
- A. When the infant's mouth surrounds the areola when feeding
- B. When the breast tissue becomes congested
- C. When the breast is emptied completely at each feeding
- D. When the infant's mouth grasps the nipple firmly
Correct Answer: B
Rationale: Engorgement is the result of venous and lymphatic stasis (congestion). Emptying the breast at each feeding, the infant grasping the nipple firmly, and the infant's mouth surrounding the areola when feeding are all measures that will aid in decreasing engorgement.
The new mother calls the nurse to her room to show how her baby is "jerking around" when she changes his position. The nurse understands that the baby is exhibiting which normal reflex?
- A. Traction reflex
- B. Babinski reflex
- C. Tonic neck reflex
- D. Moro reflex
Correct Answer: D
Rationale: The Moro reflex (startle reflex) causes the baby to abduct the extremities and fan the fingers with the thumb and index fingers making a "C" shape followed by flexion and adduction of the extremities.
A mother delivered her baby at midnight and it is now 9 a.m. She wants to sleep and asks the nurse to take care of the baby. What is this considered?
- A. Fatigue from labor
- B. Normal "taking in" response
- C. Abnormal "taking in" response
- D. Risk for altered maternal-infant bonding
Correct Answer: B
Rationale: Her primary focus will be on her own needs such as sleep ("taking in" stage).
The new mother has decided not to breastfeed the baby. How should the nurse correctly instruct the mother to suppress her milk supply?
- A. Pump the breasts to remove milk
- B. Apply warm moist compresses
- C. Restrict oral fluids
- D. Apply a firm bra and ice packs
Correct Answer: D
Rationale: If a patient is not breastfeeding, compress the breasts with a firm bra and wrapped ice packs to suppress the milk supply. Pumping the breasts and applying warm, moist compresses are instructions for the breast-feeding mother to deal with the painful symptoms of engorgement.