Nokea
Which of the following would be considered a normal assessment finding in a 1-day postpartum patient?
- A. Pinkish to brown lochia
- B. Voiding frequently 50 to 75 mL of urine
- C. Complaining of "after pains"
- D. Fundus 1 cm above the umbilicus
Correct Answer: C
Rationale: The common discomfort of after pains is a normal assessment finding at 1-day postpartum. The normal discharge 1-day postpartum would be lochia rubra, which is made up of mostly blood. The fundus would be palpated at the level of the umbilicus. Frequent voiding would be considered abnormal.
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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.
What is the first secretion produced by the breast?
- A. Prolactin
- B. Colostrum
- C. False milk
- D. Whey
Correct Answer: B
Rationale: The first secretion to be produced by the breast is colostrum.
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.
Which of the following measures could help prevent infant abduction?
- A. Only transport infants by carrying them.
- B. Require staff members to wear appropriate identification badges.
- C. Respond immediately when an alarm sounds.
- D. Never leave infants unattended at any time.
- E. Take all the infants to their mothers at the same time.
Correct Answer: B,C,D
Rationale: Staff members should always wear appropriate ID badges and should respond immediately when an alarm sounds. Infants should never be left unattended. Infants should always be transported in their cribs, never by carrying them. The nurse should transport only one infant at a time.
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.