Nokea
When assessing a mother 12 hours following the delivery of a baby where should the nurse expect to palpate the fundus?
- A. 2 cm below the umbilicus
- B. At the umbilicus
- C. 1 cm below the umbilicus
- D. Halfway between the umbilicus and the symphysis pubis
Correct Answer: B
Rationale: Within 12 hours, the fundus rises to the level of the umbilicus. The fundus should be firm. Immediately following delivery, the fundus will be felt halfway between the umbilicus and the symphysis.
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The new mother tells the home health nurse that she is concerned about her 5-day-old infant's hard dried umbilical stump. What time frame should the nurse give the mother for the umbilical stump to fall off?
Correct Answer: 10 to 14 days
Rationale: The umbilical stump will turn brownish black and fall off within 10 to 14 days after birth.
What is the term for the cream cheese-like substance that protects the infant's skin from amniotic fluid?
- A. Lanugo
- B. Meconium
- C. Desquamation
- D. Vernix caseosa
Correct Answer: D
Rationale: At birth, the skin is covered with a yellowish-white cream cheese-like substance called vernix caseosa.
What is a characteristic of a normal breast-fed infant's stool?
- A. Green and loose
- B. Dark green and sticky
- C. Pale yellow and frequent
- D. Light brown and pasty
Correct Answer: C
Rationale: Breast-fed infants tend to pass stools frequently and they are pale yellow to golden in color and pasty in consistency.
The postpartum mother with a third degree laceration tells the nurse she is afraid to have a bowel movement because of her painful episiotomy. What should the nurse do?
- A. Offer a suppository or enema.
- B. Encourage ambulation.
- C. Offer stool softeners as prescribed.
- D. Offer pain medication before defecating.
Correct Answer: C
Rationale: Stool softeners are available to ease the pain of defecation caused by hemorrhoids and birth trauma. Suppositories or enemas are contraindicated in mothers with third or fourth degree lacerations. Pain medications can often cause constipation. Ambulation may aid in defecation, but will not soften the stool.
Which tests are performed to detect inborn errors of metabolism in the newborn?
- A. Blood glucose
- B. Phenylketonuria (PKU)
- C. Blood urea nitrogen (BUN)
- D. Prothrombin time (PT)
Correct Answer: B
Rationale: State law requires certain diagnostic tests be performed on the newborn, including PKU, which detects an inborn error of metabolism.