Nokea
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.
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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.
Which statement would be a correct description of colostrum?
- A. Slightly yellow and low in protein
- B. Slightly yellow and provides antibodies
- C. Creamy and high in fat and protein
- D. Colorless and high in fat and carbohydrates
Correct Answer: B
Rationale: Colostrum is slightly yellow in color and is rich in antibodies.
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.
After delivery of a 9-lb baby the nurse assesses a perineal laceration extending through the muscles of the perineum. The nurse records this as a ___-degree laceration.
Correct Answer: second
Rationale: A second-degree laceration extends through the superficial tissues into the muscles of the perineum.
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.