Nokea
What is the appropriate way to assess the fundus of the postpartum patient?
- A. Using the side of one hand moving down from the umbilicus
- B. Using one hand over the lower segment of the uterus
- C. Using one hand pushing upward from the lower uterus
- D. Using one hand on the lower uterine segment while the other hand locates the fundus of the uterus
Correct Answer: D
Rationale: The proper way to assess the fundus of a mother who has just given birth is by placing one hand on the lower uterine segment while the other hand locates the fundus of the uterus.
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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).
What should be included in a teaching plan regarding breast engorgement?
- A. It typically occurs on the first postpartum day.
- B. It is usually first observed in the axillary region.
- C. It occurs only in women who are not breastfeeding.
- D. It occurs near the nipple on the third postpartum day.
Correct Answer: B
Rationale: Filling of the breast with milk (engorgement) usually begins in the axillary region on the third postpartum day when the milk comes in. It occurs regardless of whether the mother is breastfeeding or bottle-feeding.
A new mother had spinal anesthesia during a cesarean delivery. She now has a desire to void and can wiggle her toes. What should be the nurse's response when the mother asks to go the bathroom?
- A. Assess her blood pressure.
- B. Obtain a wheelchair.
- C. Palpate her bladder.
- D. Put slippers on her feet.
Correct Answer: D
Rationale: The nurse should check that the mother is wearing slippers to ensure better footing. If the mother has a desire to void and can move her toes, there is no need for her to remain bedridden.
Why is vitamin K given by injection to the newborn?
- A. Most mothers have a vitamin K deficiency that develops during pregnancy.
- B. Bacteria that synthesize vitamin K are not present in newborns.
- C. Vitamin K prevents the synthesis of prothrombin.
- D. The newborn does not store vitamin K.
Correct Answer: B
Rationale: Newborns are not able to synthesize vitamin K in the colon until they have adequate intestinal flora, therefore, the vitamin K injection is given as a prevention measure against hemorrhage.
Where would acrocyanosis be assessed on a newborn?
- A. Circumoral area
- B. Brow
- C. Feet
- D. Mucous membrane
Correct Answer: C
Rationale: Acrocyanosis is the slightly blue appearance of the hands and feet that is caused by poor circulation. It can last for 7 to 10 days in the newborn.