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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.
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What type of lochia will the nurse assess initially after delivery?
- A. Serosa
- B. Rubra
- C. Alba
- D. Vaginalis
Correct Answer: B
Rationale: The initial vaginal discharge after delivery is called lochia rubra. It is red and moderately heavy. Lochia rubra lasts for up to 3 days postpartum.
On the second postpartum day, a mother bathed her newborn for the first time. She tells the nurse, 'I don't think I did it right.' What postpartum psychological stage is this woman most likely in based on this comment?
- A. Taking in
- B. Taking hold
- C. Letting go
- D. Settling down
Correct Answer: B
Rationale: In phase 2, taking hold, the mother begins to initiate action and becomes interested in caring for the infant. In doing so, she may become critical of her performance.
While instructing a new mother on formula preparations, the nurse would include what types? (Select all that apply.)
- A. Ready-to-feed formula
- B. Concentrated liquid formula
- C. Powdered formula
- D. Cow's milk
- E. Canned evaporated milk
Correct Answer: A,B,C
Rationale: Formula choices are ready-to-use, concentrated liquid formula that will be diluted according to the infant's needs, and powdered formula that is mixed as needed. Cow's milk and canned evaporated milk are unsuitable, because they are nutritionally inadequate and stress the kidneys.
The nurse is giving a shower to a patient who had a cesarean section 2 days previously. What interventions should be included before, during, and after the shower? (Select all that apply.)
- A. Leave abdominal dressing open to air.
- B. Position patient with back to water stream.
- C. Cover infusion site with rubber glove.
- D. Provide a shower chair.
- E. Confirm ambulation ability.
Correct Answer: B,C,D,E
Rationale: The patient should be evaluated for ambulatory ability, and the abdominal dressing and infusion site should be covered with a waterproof cover. The patient should be provided a shower chair and positioned with her back to the water stream.
A primipara tells the nurse, 'My afterpains get worse when I am breastfeeding.' What is the most appropriate nursing response?
- A. I'll get you some aspirin to relieve the cramping that you feel.'
- B. Afterpains are more intense with your first baby.'
- C. Breastfeeding releases a hormone that causes your uterus to contract.'
- D. A change of position when you're breastfeeding might help.'
Correct Answer: C
Rationale: Breastfeeding mothers may have more afterpains because infant suckling causes the posterior pituitary to release oxytocin, which is a hormone that contracts the uterus.