Nokea
The postpartum nurse is caring for a client who gave birth to full-term twins earlier today. The nurse will know to assess for symptoms of which of the following?
- A. Postpartum infection
- B. Increased blood pressure
- C. Postpartum hemorrhage
- D. Hypoglycemia
Correct Answer: C
Rationale: Delivering twins increases the risk of postpartum hemorrhage due to larger placental sites and potential uterine overdistension.
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A postpartum nurse is teaching umbilical cord care to new parents as part of discharge teaching. The nurse would be sure to include which information in her teaching?
- A. Apply rubbing alcohol to the cord with each diaper change to help it dry out.
- B. Cover the cord with bacitracin after bathing to prevent infection.
- C. Keep the cord dry and open to the air.
- D. Wash the cord with soap and water each day during a tub bath.
Correct Answer: C
Rationale: Keeping the cord dry and exposed to air aids in proper healing.
A faculty member explains to a nursing student that the best way to prevent hemorrhage from injuries in a neonate is which of the following?
- A. Administer vitamin K1 phytonadione (AquaMEPHYTON).
- B. Handle the infant carefully while wearing soft gloves.
- C. Keep the infant swaddled in several layers of blankets.
- D. Teach the parents how to trim the babys fingernails.
Correct Answer: A
Rationale: AquaMEPHYTON is given to newborns to promote normal blood clotting. The infants intestinal tract is sterile at birth and does not have the bacteria needed to create vitamin K
When giving a newborn a bath, what is a concern for the nurse (or caregiver)?
- A. hyperbilirubinemia
- B. hypoglycemia
- C. thermoregulation
- D. contact dermatitis
Correct Answer: C
Rationale: Maintaining thermoregulation is critical during bathing to prevent hypothermia.
An infant who was stable for a day after birth now demonstrates pallor tachycardia tachypnea and circumoral cyanosis. The parent asks how the child might have a heart problem when he was stable yesterday. What information by the nurse is most accurate?
- A. Blood incompatibilities can cause this problem so we will test the mothers blood.
- B. Symptoms may not appear until fetal circulation routes begin to close after birth.
- C. The extra blood from the umbilical cord may have kept the baby stable for a while.
- D. Your baby may have gotten an infection during birth that now is causing problems.
Correct Answer: B
Rationale: This baby has clinical manifestations of tetralogy of Fallot. While the ductus arteriosus remains patent the infant remains stable. However when the ductus begins closing after the first 24 hours of life the infants cardiovascular system becomes unstable and manifestations appear. The other statements are inaccurate.
The nurse determines the fundus of a postpartum client to be boggy. Initially, what should the nurse do?
- A. Document the findings.
- B. Massage the uterine fundus until it is firm.
- C. Catheterize the client.
- D. Call the physician immediately.
Correct Answer: B
Rationale: Massaging the uterus helps to contract it and control postpartum bleeding, making it the first step in managing a boggy uterus.