1. The nurse is assessing a newborn. What sign of hypoglycemia does the nurse record?
a. Increased nasal mucus
b. Increased temperature
c. Active muscle movements
d. High-pitched cry
ANS: D
There are many signs of hypoglycemia in the newborn. One is a high-pitched cry.
DIF: Cognitive Level: Comprehension REF: Page 219 OBJ: 9
TOP: Signs of Hypoglycemia KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
2. What would the nurse expect to find when assessing the fundus of the uterus immediately
after delivery?
a. Well-contracted with its upper border at or just below the umbilicus
b. Well-contracted with its upper border three or four fingerbreadths above the
umbilicus
c. Relaxed with its upper border level with the umbilicus
d. Relaxed with its upper border two or three fingerbreadths below the umbilicus
ANS: A
Immediately after the placenta is expelled, the uterine fundus can be felt as a firm mass, about
the size of a grapefruit, at the level of the umbilicus.
3. What statement made by a new mother indicates she needs additional information about
breastfeeding?
a. “I let the baby nurse 10 to 15 minutes on the first breast and then switch to the
other breast.”
b. “The baby needs to nurse at least 5 minutes on the breast to get the hindmilk.”
c. “The baby has been nursing every 2 to 3 hours.”
d. “If the baby gets fussy between feedings, I give her a bottle of water.”
ANS: D
Supplemental feedings of formula or water should not be offered to a healthy newborn who is
breastfeeding.
, 4. After delivery, the nurse’s assessment reveals a soft, boggy uterus located above the level of
the umbilicus. What is the most appropriate nursing intervention?
a. Notify the physician.
b. Massage the fundus.
c. Initiate measures that encourage voiding.
d. Position the patient flat.
ANS: B
A poorly contracted uterus should be massaged until firm to prevent hemorrhage.
5. What type of lochia will the nurse assess initially after delivery?
a. Serosa
b. Rubra
c. Alba
d. Vaginalis
ANS: B
The initial vaginal discharge after delivery is called lochia rubra. It is red and moderately
heavy. Lochia rubra lasts for up to 3 days postpartum.
6. A woman will be discharged 48 hours after a vaginal delivery. When planning discharge
teaching, the nurse would include what information about lochia?
a. Lochia should disappear 2 to 4 weeks postpartum.
b. It is normal for the lochia to have a slightly foul odor.
c. A change in lochia from pink to bright red should be reported.
d. A decrease in flow will be noticed with ambulation and activity.
ANS: C
A return to bright red lochia rubra may indicate a late postpartum hemorrhage and must be
reported.
7. What instruction should the nurse teach the postpartum woman about perineal self-care?
a. Perform perineal self-care at least twice a day.
b. Cleanse with warm water in a squeeze bottle from front to back.
c. Remove perineal pads from the rectal area toward the vagina.
d. Use cool water to decrease edema of the perineum.
ANS: B
Cleansing from front to back prevents contamination from the rectal area.
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