Nokea
When is breast engorgement most likely to occur?
- A. When the infant's mouth surrounds the areola when feeding
- B. When the breast tissue becomes congested
- C. When the breast is emptied completely at each feeding
- D. When the infant's mouth grasps the nipple firmly
Correct Answer: B
Rationale: Engorgement is the result of venous and lymphatic stasis (congestion). Emptying the breast at each feeding, the infant grasping the nipple firmly, and the infant's mouth surrounding the areola when feeding are all measures that will aid in decreasing engorgement.
You may also like to solve these questions
Which newborn assessment finding can suggest a chromosomal disorder?
- A. Epstein pearls
- B. Gynecomastia
- C. Babinski reflex
- D. Simian crease
Correct Answer: D
Rationale: A simian crease may indicate a chromosomal disorder.
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.
Which finding should the nurse suspect as abnormal in the newborn during the initial assessment?
- A. Eyes crossed at times
- B. Persistent high-pitched cry
- C. Arms and legs flexed
- D. Slight bluish tinge of the extremities
Correct Answer: B
Rationale: A high-pitched cry may indicate neurologic problems. Occasional crossing of the eyes, flexing of the arms and legs, and a bluish tinge of the extremities are all considered normal assessment findings in the newborn.
What is the name of the vaginal discharge that occurs immediately following delivery?
- A. Lochia serosa
- B. Lochia rubra
- C. Lochia palatine
- D. Lochia alba
Correct Answer: B
Rationale: The vaginal discharge that occurs immediately following discharge is known as lochia rubra and is made up mostly of blood. As the placenta heals, the draining turns pink to dark brown in color and is known as lochia serosa. After about 7 days, the discharge turns slight yellow to white and is called lochia alba.
The nurse is observing a new mother interact with her infant. Which observation would indicate that bonding is occurring?
- A. The mother is making eye contact with the infant.
- B. The mother is sending the infant to the nursery for feedings.
- C. The mother is cuddling with the infant and napping.
- D. The mother is requesting that the mother-in-law change all diapers.
- E. The mother states that her favorite thing to do with her baby is to breastfeed.
Correct Answer: A,C,E
Rationale: Eye contact, cuddling, and enjoying infant feeding are all signs of positive parent-infant attachment (bonding). Sending the infant to the nursery for feedings and having someone else change all diapers could indicate difficulty with bonding.