Nokea
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.
You may also like to solve these questions
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.
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 nurse is giving a bath demonstration for a group of new mothers. What should be included in the demonstration?
- A. Apply baby powder generously to keep baby dry.
- B. Cleanse perineum from front to back.
- C. Use scented soap to make baby smell good.
- D. Partially submerge head in water when shampooing.
Correct Answer: B
Rationale: The perineum should be cleansed by wiping from the anterior to the posterior. Excessive use of powders and scented soaps can irritate the skin. The head should not be submerged in water.
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.