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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.
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After birth, the nurse quickly dries and wraps the newborn in a blanket. How does this action prevent heat loss?
- A. Conduction
- B. Radiation
- C. Evaporation
- D. Convection
Correct Answer: C
Rationale: Newborns lose heat quickly after birth as fluid evaporates from their bodies.
What should the nurse implement for security purposes when bringing the infant from the nursery to the mother?
- A. Ask, 'Is this your band number?'
- B. Confirm room number of mother.
- C. Ask the mother to identify herself verbally.
- D. Check the band number of the infant with that of the mother.
Correct Answer: D
Rationale: The nurse should check the band number of the infant with that of the mother by asking the mother to verbally read the number.
Below what blood glucose level is the newborn considered hypoglycemic?
- A. Below 70 mg/dL
- B. Below 60 mg/dL
- C. Below 50 mg/dL
- D. Below 40 mg/dL
Correct Answer: D
Rationale: A blood glucose level of less than 40 mg/dL is considered hypoglycemic. If the screening sample is below 40 mg/dL, a venous sample will be drawn. After the blood has been drawn, the infant should be fed to prevent a further drop.
What postpartum exercises should the nurse teach a patient who had a vaginal delivery yesterday? (Select all that apply.)
- A. Abdominal tighteners
- B. Head lift
- C. Pelvic tilt
- D. Kegel exercises
- E. Leg lifts
Correct Answer: A,B,C,D
Rationale: Exercises for postpartum involution such as abdominal tighteners, head lifts, pelvic tilts, and Kegel exercises are acceptable. Leg lifts are too strenuous early in the postpartum period.
What would the nurse expect to find when assessing the fundus of the uterus immediately after delivery?
- A. Well-contracted with its upper border at or just below the umbilicus
- B. Well-contracted with its upper border three or four fingerbreadths above the umbilicus
- C. Relaxed with its upper border level with the umbilicus
- D. Relaxed with its upper border two or three fingerbreadths below the umbilicus
Correct Answer: A
Rationale: Immediately after the placenta is expelled, the uterine fundus can be felt as a firm mass, about the size of a grapefruit, at the level of the umbilicus.