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The nurse is teaching the parents of a female baby how to change the baby's diapers. Which of the following should be included in the teaching?
- A. Always wipe the perineum from front to back.
- B. Remove any vernix caseosa from the labial folds.
- C. Put powder on the buttocks every time the baby stools.
- D. Weigh every diaper to assess hydration status.
Correct Answer: A
Rationale: Front-to-back wiping prevents urinary tract infections.
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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.
Which maternal event is abnormal in the early postpartal period?
- A. Diuresis and diaphoresis
- B. Flatulence and constipatiNon R I G
- C. Extreme hunger and thirst
- D. Lochial color changes from rubra to alba
Correct Answer: D
Rationale: The correct answer is D because the normal progression of lochia after childbirth is from rubra (red) to serosa (pinkish-brown) to alba (yellow-white). This signifies the normal healing process of the uterus. Choices A, B, and C are all normal postpartum events. Diuresis and diaphoresis help eliminate excess fluid from pregnancy, flatulence and constipation can occur due to hormonal changes and decreased muscle tone, and extreme hunger and thirst are common as the body recovers from childbirth.
Which of the following is a priority nursing diagnosis for a woman, G10 P6226, who is PP1 from a spontaneous vaginal delivery with a significant postpartum hemorrhage?
- A. Alteration is comfort related to afterbirth pains.
- B. Risk for altered parenting related to grand multiparity.
- C. Fluid volume deficit related to blood loss.
- D. Risk for sleep deprivation related to mothering role.
Correct Answer: C
Rationale: Hemorrhage causes fluid loss.
A 2-day-old breastfeeding baby born via normal spontaneous vaginal delivery has just been weighed in the newborn nursery. The nurse determines that the baby has lost 3.5% of the birth weight. Which of the following nursing actions is appropriate?
- A. Do nothing because this is a normal weight loss.
- B. Notify the neonatologist of the significant weight loss.
- C. Advise the mother to bottle feed the baby at the next feed.
- D. Assess the baby for hypoglycemia with a glucose monitor.
Correct Answer: A
Rationale: Weight loss up to 7-10% is considered normal in the first few days due to fluid loss; 3.5% does not warrant immediate intervention.
A client is receiving an IV heparin drip at 16 mL/hr via an infusion pump for a diagnosis of deep vein thrombosis. The label on the 1/2 liter bag of D5W indicates 25,000 units of heparin have been added. How many units of heparin is the client receiving per hour? (Calculate to the nearest whole.)
- A. 800
- B. NA
- C. NA
- D. NA
Correct Answer: A
Rationale: Calculation: 25,000 units ÷ 500 mL × 16 mL = 800 units.