Chapter 27: Care of the Mother and Newborn My Nursing Test Banks

Chapter 27: Care of the Mother and Newborn

Cooper and Gosnell: Foundations and Adult Health Nursing, 7th Edition

MULTIPLE CHOICE

1.When assessing a mother 12 hours following the delivery of a baby, where should the nurse expect to palpate the fundus?

a. 2 cm below the umbilicus
b. At the umbilicus
c. 1 cm below the umbilicus
d. Halfway between the umbilicus and the symphysis pubis

ANS: B

Within 12 hours, the fundus rises to the level of the umbilicus. The fundus should be firm. Immediately following delivery, the fundus will be felt halfway between the umbilicus and the symphysis.

PTS: 1 DIF: Cognitive Level: Application REF: Page 835

OBJ: 1 TOP: Postpartum KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

2.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

ANS: B

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.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 835

OBJ: 1 TOP: Lochia KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

3.What is the first secretion produced by the breast?

a. Prolactin
b. Colostrum
c. False milk
d. Whey

ANS: B

The first secretion to be produced by the breast is colostrum.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 837

OBJ: 2 TOP: Lactation KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

4.What should be included in a teaching plan regarding breast engorgement?

a. It typically occurs on the first postpartum day
b. It is usually first observed in the axillary region
c. It occurs only in women who are not breastfeeding
d. It occurs near the nipple on the third postpartum day

ANS: B

Filling of the breast with milk (engorgement) usually begins in the axillary region on the third postpartum day when the milk comes in. It occurs regardless of whether the mother is breastfeeding or bottle-feeding.

PTS: 1 DIF: Cognitive Level: Application REF: Page 851

OBJ:2TOP:Engorgement

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

5.When is breast engorgement most likely to occur?

a. When the infants 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 infants mouth grasps the nipple firmly

ANS: B

Engorgement is the result of venous and lymphatic stasis (congestion). Emptying the breast at each feeding, the infant grasping the nipple firmly, and the infants mouth surrounding the areola when feeding are all measures that will aid in decreasing engorgement.

PTS: 1 DIF: Cognitive Level: Application REF: Page 851

OBJ:2TOP:Engorgement

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

6.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

ANS: B

Colostrum is slightly yellow in color and is rich in antibodies.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 866

OBJ: 13 TOP: Colostrum KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

7.The new mother has decided not to breastfeed the baby. How should the nurse correctly instruct the mother to suppress her milk supply?

a. Pump the breasts to remove milk
b. Apply warm, moist compresses
c. Restrict oral fluids
d. Apply a firm bra and ice packs

ANS: D

If a patient is not breastfeeding, compress the breasts with a firm bra and wrapped ice packs to suppress the milk supply. Pumping the breasts and applying warm, moist compresses are instructions for the breastfeeding mother to deal with the painful symptoms of engorgement.

PTS: 1 DIF: Cognitive Level: Application REF: Page 851

OBJ:3TOP:Engorgement

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

8.During the immediate postpartum period, the mother has a temperature of 100.2 F, pulse 52, respirations 18, BP 138/84. What should the nurse do?

a. Report the temperature as abnormal
b. Continue to monitor every 15 minutes
c. Report the pulse as abnormal
d. Nothing as the vital signs are normal

ANS: D

The vital signs are normal for a new postpartum patient.

PTS: 1 DIF: Cognitive Level: Application REF: Page 846, Table 27-2

OBJ: 1 TOP: Postpartum KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

9.Within the first hour following a vaginal delivery, the nurse assesses the mother and finds the fundus is firm and there is a trickle of bright red blood. What should be the nurses reaction to the assessment?

a. This is a normal occurrence.
b. This is abnormal and should be reported.
c. The patient should be administered a blood thinner.
d. The patient should be restricted to bed rest.

ANS: A

A bright red drainage is normal immediately after delivery. The patient should be monitored at regular intervals. Bed rest is not indicated. A blood thinner would not be given.

PTS: 1 DIF: Cognitive Level: Application REF: Page 835

OBJ: 1 TOP: Postpartum KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

10.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

ANS: D

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.

PTS: 1 DIF: Cognitive Level: Application REF: Page 835, Figure 27-1

OBJ:1TOP:Fundal assessment

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

11.The postpartum mother with a third degree laceration tells the nurse she is afraid to have a bowel movement because of her painful episiotomy. What should the nurse do?

a. Offer a suppository or enema
b. Encourage ambulation
c. Offer stool softeners as prescribed
d. Offer pain medication before defecating

ANS: C

Stool softeners are available to ease the pain of defecation caused by hemorrhoids and birth trauma. Suppositories or enemas are contraindicated in mothers with third or fourth degree lacerations. Pain medications can often cause constipation. Ambulation may aid in defecation, but will not soften the stool.

PTS: 1 DIF: Cognitive Level: Application REF: Page 837

OBJ:3TOPostpartum elimination

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

12.A new mother had spinal anesthesia during a cesarean delivery. She now has a desire to void and can wiggle her toes. What should be the nurses response when the mother asks to go the bathroom?

a. Assess her blood pressure
b. Obtain a wheelchair
c. Palpate her bladder
d. Put slippers on her feet

ANS: D

The nurse should check that the mother is wearing slippers to ensure better footing. If the mother has a desire to void and can move her toes, there is no need for her to remain bedridden.

PTS: 1 DIF: Cognitive Level: Application REF: Page 847

OBJ:3TOPostspinal anesthesia

KEY:Nursing Process Step: Implementation

MSC:NCLEX: Safe, Effective Care Environment

13.A mother delivered her baby at midnight and it is now 9 AM. She wants to sleep and asks the nurse to take care of the baby. What is this considered?

a. Fatigue from labor
b. Normal taking in response
c. Abnormal taking in response
d. Risk for altered maternal-infant bonding

ANS: B

Her primary focus will be on her own needs such as sleep (taking in stage).

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 851, Box 27-9, 854

OBJ:5TOP:Taking in response

KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity

14.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 mL to 75 mL of urine
c. Complaining of after pains
d. Fundus 1 cm above the umbilicus

ANS: C

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.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 854

OBJ: 2 TOP: Postpartum KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

15.A new Native American mother tells the nurse that when she goes home, her mother-in-law will be caring for the baby while she rests. The nurse has concerns. What should the nurse do?

a. Explain the importance of ambulating to recover
b. Explain the importance of maternal-infant bonding
c. Explore ways to blend this with safe health teaching
d. Encourage this cultural behavior

ANS: C

Follow principles that facilitate nursing practice within transcultural situations.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 857

OBJ:5TOP:Ethnic considerations

KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity

16.Before initially feeding an infant, what reflex should the nurse assess?

a. Moro reflex
b. Rooting reflex
c. Babinski reflex
d. Swallow reflex

ANS: D

The nurse should verify that the infant is able to swallow normally before feeding.

PTS: 1 DIF: Cognitive Level: Application REF: Page 861, Table 27-5

OBJ: 9 TOP: Postpartum KEY: Nursing Process Step: Assessment

MSC:NCLEX: Safe, Effective Care Environment

17.Following delivery of the newborn, which nursing intervention should be carried out immediately?

a. Weigh the infant
b. Warm the infant
c. Bathe the infant
d. Inoculate the infant

ANS: B

Maintenance of body temperature is the primary concern when caring for the newborn. The infant will also be weighed, bathed, and inoculated, but those measures are not the primary concern.

PTS: 1 DIF: Cognitive Level: Application REF: Page 867

OBJ:8TOP:Newborn care

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

18.Where would acrocyanosis be assessed on a newborn?

a. Circumoral area
b. Brow
c. Feet
d. Mucous membrane

ANS: C

Acrocyanosis is the slightly blue appearance of the hands and feet that is caused by poor circulation. It can last for 7 to 10 days in the newborn.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 859

OBJ:7TOP:Newborn assessment

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

19.The nurse identifies that the newborn is jaundiced within the first 24 hours of birth, with jaundice occurring over bony prominences of the face and the mucous membrane. What type of jaundice does this represent?

a. Physiological
b. Normal
c. Pathologic
d. Transitory

ANS: C

Jaundice that appears within the first 48 hours of life is termed pathologic jaundice and is abnormal. Pathologic jaundice indicates excessive red blood cell destruction and it should be reported. Jaundice that appears after the first 48 hours of life is known as physiological jaundice and is considered normal.

PTS: 1 DIF: Cognitive Level: Application REF: Page 860

OBJ:9TOP:Newborn assessment

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

20.What is the term for the cream cheeselike substance that protects the infants skin from amniotic fluid?

a. Lanugo
b. Meconium
c. Desquamation
d. Vernix caseosa

ANS: D

At birth, the skin is covered with a yellowish-white cream cheeselike substance called vernix caseosa.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 860

OBJ:8TOP:Newborn assessment

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

21.Which tests are performed to detect inborn errors of metabolism in the newborn?

a. Blood glucose
b. Phenylketonuria (PKU)
c. Blood urea nitrogen (BUN)
d. Prothrombin time (PT)

ANS: B

State law requires certain diagnostic tests be performed on the newborn, including PKU, which detects an inborn error of metabolism.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 866

OBJ:7TOP:Newborn care

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

22.Which newborn assessment finding can suggest a chromosomal disorder?

a. Epstein pearls
b. Gynecomastia
c. Babinski reflex
d. Simian crease

ANS: D

A simian crease may indicate a chromosomal disorder.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 865

OBJ:9TOP:Newborn assessment

KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance

23.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.

ANS: B

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.

PTS: 1 DIF: Cognitive Level: Application REF: Page 866

OBJ:8TOP:Care of newborn

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

24.What should be included when discussing the care of a circumcised infant after discharge from the hospital?

a. Gently remove the yellow exudate from the foreskin.
b. Apply sterile petroleum gauze after each diaper change.
c. Wipe the circumcision with alcohol each day.
d. Avoid the use of cloth diapers until the foreskin has healed.

ANS: B

Wash the penis at diaper change and apply sterile petroleum gauze. The yellow exudate should not be removed as it is part of the normal healing process. The circumcised area should be cleansed gently, not with alcohol. Cloth diapers are sometimes recommended to promote healing.

PTS: 1 DIF: Cognitive Level: Application REF: Page 868

OBJ:11TOP:Circumcision

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

25.The nurse is caring for a newborn who was circumcised earlier in the day. What should be included in the plan of care?

a. Administration of a topical anesthetic to the site
b. Application of ice to stop bleeding
c. Retraction of any remaining foreskin
d. Observation for bleeding for the first 12 hours

ANS: D

The nurse should assess for bleeding for the first 12 hours following the circumcision. Gentle pressure should be applied to control bleeding. The administration of topical anesthetic and the retraction of the remaining foreskin are not included in the plan of care.

PTS: 1 DIF: Cognitive Level: Application REF: Page 868

OBJ:11TOP:Circumcision

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

26.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

ANS: B

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.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 870

OBJ:9TOP:Newborn assessment

KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance

27.What is characteristic of a normal breastfed infants stool?

a. Green and loose
b. Dark green and sticky
c. Pale yellow and frequent
d. Light brown and pasty

ANS: C

Breastfed infants tend to pass stools frequently and they are pale yellow to golden in color and pasty in consistency.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 869

OBJ:8TOP:Breastfed stool

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

28.The new mother calls the nurse to her room to show how her baby is jerking around when she changes his position. The nurse understands that the baby is exhibiting which normal reflex?

a. Traction reflex
b. Babinski reflex
c. Tonic neck reflex
d. Moro reflex

ANS: D

The Moro reflex (startle reflex) causes the baby to abduct the extremities and fan the fingers with the thumb and index fingers making a C shape followed by flexion and adduction of the extremities.

PTS: 1 DIF: Cognitive Level: Application REF: Page 863, Table 27-5

OBJ: 10 TOP: Reflexes KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

29.The nurse is giving a bath demonstration for a group of new mothers. What should be included in the demonstration?

a. Apply baby powder generously to keep baby dry.
b. Cleanse perineum from front to back.
c. Use scented soap to make baby smell good.
d. Partially submerge head in water when shampooing.

ANS: B

The perineum should be cleansed by wiping from the anterior to the posterior. Excessive use of powders and scented soaps can irritate the skin. The head should not be submerged in water.

PTS: 1 DIF: Cognitive Level: Application REF: Page 869

OBJ:4TOP:Newborn bath

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

MULTIPLE RESPONSE

30.Which of the following measures could help prevent infant abduction? (Select all that apply.)

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

ANS: B, C, D

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.

PTS: 1 DIF: Cognitive Level: Application REF: Page 857

OBJ:6TOP:Infant abduction

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

31.The nurse is observing a new mother interact with her infant. Which observation would indicate that bonding is occurring? (Select all that apply.)

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.

ANS: A, C, E

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.

PTS: 1 DIF: Cognitive Level: Application REF: Page 870

OBJ: 12 TOP: Bonding KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

32.A new mother asks for advice on how to quiet her fussy newborn. Which responses would be appropriate to suggest to the mother? (Select all that apply.)

a. Prewarm the crib sheets with a hot water bottle
b. Swaddle the newborn tightly in a receiving blanket
c. Place the baby in a larger crib or infant bed
d. Offer a pacifier or allow the infant to suckle at the breast
e. Take the infant for a ride in the car

ANS: A, B, D, E

Oftentimes, infants are comforted by warm sheets. Infants tend to like to be swaddled snugly. Many infants find comfort sucking a pacifier; breastfed infants can suckle at the breast. Car rides are often soothing for infants. A large sleeping space is not soothing for infants. The opposite is true. A small sleeping space, such as a bassinette, tends to comfort a fussy baby.

PTS: 1 DIF: Cognitive Level: Application REF: Page 870

OBJ:14TOP:Infant quieting techniques

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

COMPLETION

33.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.

ANS:

second

A second-degree laceration extends through the superficial tissues into the muscles of the perineum.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 836

OBJ:3TOP:Second-degree lacerations

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

34.The nurse describes the return of the postpartum patients uterus to a pregravid state as ________________.

ANS:

involution

Involution is the decrease in size of the uterus to a prepregnant state.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 835

OBJ: 2 TOP: Involution KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

35.The new mother tells the home health nurse that she is concerned about her 5-day-old infants hard, dried umbilical stump. What time frame should the nurse give the mother for the umbilical stump to fall off? ________________________ days

ANS:

10 to 14

ten to fourteen

The umbilical stump will turn brownish black and fall off within 10 to 14 days after birth.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 861

OBJ:4TOP:Mummification

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

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