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Which symptom would the nurse expect to observe in a postpartum client with a vaginal hematoma?
- A. Pain.
- B. Bleeding.
- C. Warmth.
- D. Redness.
Correct Answer: A
Rationale: Pain is a common symptom of a vaginal hematoma.
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The nurse is assessing a newborn on admission to the newborn nursery. Which of the following findings should the nurse report to the neonatologist?
- A. Intracostal retractions.
- B. Caput succedaneum.
- C. Epstein's pearls.
- D. Harlequin sign.
Correct Answer: A
Rationale: Intracostal retractions indicate respiratory distress and require immediate attention.
A nurse on the postpartum unit is caring for two postoperative cesarean clients. One client had spinal anesthesia for the delivery and the other client had an epidural. Which of the following complications will the nurse monitor the spinal client for that the epidural client is much less high risk for?
- A. Pruritus.
- B. Nausea.
- C. Postural headache.
- D. Respiratory depression.
Correct Answer: C
Rationale: Spinal anesthesia increases the risk of postural headaches.
To reduce the risk of hypoglycemia in a full-term newborn weighing 2,900 grams, what should the nurse do?
- A. Maintain the infant's temperature above 97.7°F.
- B. Feed the infant glucose water every 3 hours until breastfeeding well.
- C. Assess blood glucose levels every 3 hours for the first twelve hours.
- D. Encourage the mother to breastfeed every 4 hours.
Correct Answer: A
Rationale: Maintaining body temperature helps prevent hypoglycemia by reducing metabolic demands.
What theory developed by Ramona Mercer focused on the process of becoming a mother?
- A. Maternal Role Attainment
- B. Postpartum Adapting
- C. Postpartum Maternal Change
- D. Maternal Encouragement
Correct Answer: A
Rationale: The correct answer is A: Maternal Role Attainment. Mercer's theory emphasizes the process through which a woman acquires the maternal role, including changes in behavior, attitudes, and values. Choice B, Postpartum Adapting, is vague and doesn't specifically address the process of becoming a mother. Choice C, Postpartum Maternal Change, is too general and lacks the focus on role attainment. Choice D, Maternal Encouragement, is not a theory developed by Ramona Mercer and does not capture the essence of the maternal role attainment process.
During the first 8 hours postpartum, the nurse will demonstrate how to perform a fundal massage and assist with breast-feeding techniques. What other assessment is important at this time?
- A. assessment of partner changing a diaper
- B. assessment of vaginal bleeding
- C. assessment of social support
- D. assessment of family dynamics
Correct Answer: B
Rationale: The correct answer is B: assessment of vaginal bleeding. During the first 8 hours postpartum, it is crucial to monitor vaginal bleeding to assess for any signs of excessive bleeding or hemorrhage, which are common postpartum complications. This assessment helps in early detection and prompt intervention if necessary.
Other choices are incorrect:
A: assessment of partner changing a diaper - While involving the partner in care is beneficial, it is not a priority assessment during this crucial postpartum period.
C: assessment of social support - Important for overall well-being but not as critical as monitoring vaginal bleeding for immediate postpartum complications.
D: assessment of family dynamics - While family dynamics play a role in postpartum care, it is not a priority assessment in the initial 8 hours.