Chapter 9: The Family After Birth My Nursing Test Banks

Chapter 9: The Family After Birth

Elsevier items and derived items 2007 by Saunders, an imprint of Elsevier Inc.

MULTIPLE CHOICE

1. The nurse assessing a newborn recognizes a sign of hypoglycemia, which is:

a.

Increased respiratory rate

b.

Increased temperature

c.

Active muscle tone

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: Text Reference: 222

OBJ: Objective: 7 TOP: Topic: Care of the Newborn

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Reduction of Risk

2. The nurse assessing the fundus of the uterus immediately after delivery would expect to find the uterus:

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.

DIF: Cognitive Level: Analysis REF: Text Reference: 200

OBJ: Objective: 4 TOP: Topic: Postpartum Assessment

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

3. The statement made by a new mother that indicates she needs additional information about breastfeeding is:

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.

DIF: Cognitive Level: Analysis REF: Text Reference: 228

OBJ: Objective: 8 TOP: Topic: Breastfeeding

KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

4. Following delivery, the nurses assessment reveals a soft, boggy uterus located above the level of the umbilicus. The appropriate intervention is to:

a.

Notify the doctor

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.

DIF: Cognitive Level: Application REF: Text Reference: 201

OBJ: Objective: 4 TOP: Topic: Postpartum Assessment

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

5. The nurse assesses the initial lochia postdelivery, which is:

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.

DIF: Cognitive Level: Knowledge REF: Text Reference: 201

OBJ: Objective: 4 TOP: Topic: Postpartum Changes-Reproductive System

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

6. A woman will be discharged 48 hours after a vaginal delivery. When planning discharge teaching, the information the nurse would include about lochia is:

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.

DIF: Cognitive Level: Application REF: Text Reference: 202

OBJ: Objective: 4 TOP: Topic: Postpartum Changes-Reproductive System

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

7. The nurse should teach the postpartum woman about perineal self-care by instructing her to:

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.

DIF: Cognitive Level: Application REF: Text Reference: 205

OBJ: Objective: 4 TOP: Topic: Postpartum Changes-Reproductive System

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection

8. The nurse can expect which of the following interventions to be ordered if the postpartum woman is not immune to rubella?

a.

The rubella virus vaccine should be administered before discharge.

b.

The woman should receive the rubella virus vaccine at her 6-week postpartum checkup.

c.

The woman should be instructed not to get pregnant until she receives the rubella vaccine.

d.

No intervention is indicated at this time because the woman is not at risk for rubella.

ANS: A

The woman who is not immune to rubella is immunized in the immediate postpartum period because there is no danger of her being pregnant.

DIF: Cognitive Level: Analysis REF: Text Reference: 208

OBJ: Objective: 4 TOP: Topic: Postpartum Changes-Immune System

KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection

9. The statement that indicates the new mother is breastfeeding correctly is:

a.

I will put the baby first on the breast that she took last in the previous feeding.

b.

I keep the baby on a 4-hour feeding schedule.

c.

I let the baby stay on the first breast for 20 minutes.

d.

I put only the nipple in the babys mouth when I am breastfeeding.

ANS: A

Alternating breasts increases milk production, particularly hindmilk, which has a higher protein and fat content.

DIF: Cognitive Level: Analysis REF: Text Reference: 227

OBJ: Objective: 8 TOP: Topic: Breastfeeding

KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

10. The nurse counseling a lactating mother about diet would include instructions to:

a.

Consume 500 more calories than her usual prepregnancy diet.

b.

Eat less meat and more fruits and vegetables.

c.

Drink 3 to 4 tall glasses of fluid daily.

d.

Eat 1,000 more calories than her usual prepregnancy diet.

ANS: A

To maintain nutrient stores while breastfeeding, the mother needs 500 additional calories each day over her prepregnancy diet.

DIF: Cognitive Level: Comprehension REF: Text Reference: 230

OBJ: Objective: 8 TOP: Topic: Breastfeeding-Maternal Nutrition

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

11. When a woman asks about resumption of her menstrual cycle after childbirth, the nurse responds that:

a.

A woman will not ovulate in the absence of menstrual flow.

b.

Most nonlactating women resume menstruation about 2 months postpartum.

c.

Generally, a woman does not ovulate in the first few cycles after childbirth.

d.

The return of menstruation is delayed when a woman does not breastfeed.

ANS: B

Menstrual periods resume in about 6 to 8 weeks if the woman is not breastfeeding.

DIF: Cognitive Level: Comprehension REF: Text Reference: 204

OBJ: Objective: 4 TOP: Topic: Postpartum Changes

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

12. The nurse explains that the physician will order RhoGAM in the event that a/an:

a.

Unsensitized Rh-negative mother has an Rh-positive pregnancy.

b.

Rh-negative mother becomes sensitized.

c.

Sensitized infant has a rising bilirubin level.

d.

Unsensitized infant exhibits no outward signs.

ANS: A

The Rh-negative woman should receive RhoGAM within 72 hours after the birth of an Rh-positive infant.

DIF: Cognitive Level: Analysis REF: Text Reference: 208

OBJ: Objective: 4 TOP: Topic: Postpartum Changes-Immune System

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

13. After birth, the nurse quickly dries and wraps the newborn in a blanket to prevent heat loss by:

a.

Conduction

b.

Radiation

c.

Evaporation

d.

Convection

ANS: C

Newborns lose heat quickly after birth as fluid evaporates from their bodies.

DIF: Cognitive Level: Comprehension REF: Text Reference: 215

OBJ: Objective: 7 TOP: Topic: Newborn Care

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

14. The nurses instructions for a new mother to care for the babys umbilical cord will include:

a.

The area should be kept covered with a sterile dressing.

b.

Clean the stump with alcohol at every diaper change.

c.

Keep the clamp on until the cord falls off.

d.

Give the newborn a daily tub bath until the cord falls off.

ANS: B

Alcohol is applied at each diaper change to promote drying of the cord, thus preventing infection.

DIF: Cognitive Level: Application REF: Text Reference: 219

OBJ: Objective: 10 TOP: Topic: Newborn Care

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

15. A new mother states her preference to formula-feed her newborn. The nurse planning discharge instructions would tell her about a measure to help suppress lactation and promote comfort, which is:

a.

Wear a well-fitting bra continuously for several days.

b.

Stand in a warm shower, letting the water spray over the breasts.

c.

Express small amounts of milk from the breasts several times a day.

d.

Massage the breasts when they ache.

ANS: A

When a mother does not wish to breastfeed, a snug bra worn around the clock can help alleviate discomfort from engorgement.

DIF: Cognitive Level: Application REF: Text Reference: 204-205

OBJ: Objective: 4 TOP: Topic: Postpartum Changes-Reproductive System

KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance

16. On the second postpartum day, a mother bathed her newborn for the first time. She tells the nurse, I dont think I did it right. Based on the mothers comment, she is most likely in the postpartum psychological stage of:

a.

Taking in

b.

Taking hold

c.

Letting go

d.

Settling down

ANS: B

In phase 2, taking hold, the mother begins to initiate action and becomes interested in caring for the baby. In doing so, she may become critical of her performance.

DIF: Cognitive Level: Analysis REF: Text Reference: 211

OBJ: Objective: 6 TOP: Topic: Postpartum Changes-Emotional Care

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Psychosocial Integrity: Physiological Adaptation

17. A primipara tells the nurse, My afterpains get worse when I am breastfeeding. The most appropriate nursing response would be:

a.

Ill get you some aspirin to relieve the cramping that you feel.

b.

Afterpains are more intense with your first baby.

c.

Breastfeeding releases a hormone that causes your uterus to contract.

d.

A change of position when youre breastfeeding might help.

ANS: C

Breastfeeding mothers may have more afterpains because infant suckling causes the posterior pituitary to release oxytocin, which is a hormone that contracts the uterus.

DIF: Cognitive Level: Analysis REF: Text Reference: 201

OBJ: Objective: 4 TOP: Topic: Postpartum Changes-Reproductive System

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

18. A new mother has decided not to breastfeed her newborn. The nurse planning to teach the mother about formula feeding would include:

a.

Position the bottle so that the nipple is full of formula during the entire feeding.

b.

Infant formula can be heated safely in a microwave.

c.

Burp the baby after 4 ounces and again when the bottle is empty.

d.

Do not prop a bottle for a feeding until the baby is older.

ANS: A

The nipple of the bottle should be kept full of formula to reduce the amount of air the baby swallows.

DIF: Cognitive Level: Comprehension REF: Text Reference: 232

OBJ: Objective: 8 TOP: Topic: Formula Feeding

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Reduction of Risk

19. In the recovery room, the nurse checks the newly delivered womans fundus following a cesarean section. How would the nurse proceed with this assessment?

a.

Palpate from the midline to the side of body

b.

Palpate from the symphysis to the umbilicus

c.

Palpate from the side of the uterus to the midline

d.

Massage the abdomen in a circular motion

ANS: C

The fundus is checked gently by walking the fingers from the side of the uterus to the midline.

DIF: Cognitive Level: Application REF: Text Reference: 211

OBJ: Objective: 5 TOP: Topic: Postpartum Assessment-Cesarean Birth

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

20. The nurse instructed a postpartum woman about storing and freezing breast milk. The nurse determines that the teaching was effective when the woman says:

a.

I can thaw frozen breast milk in the microwave.

b.

Ill put enough breast milk for one day in a container.

c.

Breast milk can be stored in glass containers.

d.

Breast milk can be kept in the refrigerator for up to 3 months.

ANS: C

Breast milk can be safely stored in glass or clear hard plastic containers.

DIF: Cognitive Level: Analysis REF: Text Reference: 230

OBJ: Objective: 8 TOP: Topic: Breastfeeding

KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

MULTIPLE RESPONSE

1. While instructing a new mother on formula preparation, the nurse will include information about formula choices, such as:

Select all that apply.

a.

Ready-to-feed formula

b.

Concentrated liquid formula

c.

Powdered formula

d.

Cows milk

e.

Canned evaporated milk

ANS: A, B, C

Formula choices are ready-to-use, concentrated liquid formula that will be diluted according to the babys needs, and powdered formula that is mixed as needed. Cows milk and canned evaporated milk are unsuitable because they are nutritionally inadequate and stress the kidneys.

DIF: Cognitive Level: Comprehension REF: Text Reference: 231

OBJ: Objective: 8 TOP: Topic: Formula Choices

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

COMPLETION

1. The nurse assesses a 6-inch stain of rubra lochia on a pad that was worn for 2 hours. The nurse would document this as a ____________________ amount of lochia.

ANS: moderate

DIF: Cognitive Level: Application REF: Text Reference: 202, Skill 9-1

OBJ: Objective: 4 TOP: Topic: Estimating Lochia Discharge

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Reduced Risk

NOT: Rationale: A 6-inch stain on a pad worn 2 hours is regarded as a moderate amount of lochia discharge.

2. The nurse explains that the only absolute contraindication for a mother to breastfeed her child is ____________________ infection.

ANS: HIV

DIF: Cognitive Level: Comprehension REF: Text Reference: 222

OBJ: Objective: 2 TOP: Topic: Contraindication for Breast Feeding

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection

NOT: Rationale: Mothers who are HIV positive should not breastfeed because the virus can be transmitted through breast milk.

3. The hormone responsible for milk production is ____________________.

ANS: prolactin

DIF: Cognitive Level: Knowledge REF: Text Reference: 230

OBJ: Objective: 8 TOP: Topic: Milk Production Hormone

KEY: Nursing Process Step: N/A

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

NOT: Rationale: During pregnancy, the woman secretes high levels of prolactin, the hormone that causes milk production. Following delivery, increased levels of prolactin lead to lactation.

4. The hormone responsible for milk let-down or ejection from the breasts is ____________________.

ANS: oxytocin

DIF: Cognitive Level: Knowledge REF: Text Reference: 230

OBJ: Objective: 8 TOP: Topic: Breastfeeding

KEY: Nursing Process Step: N/A

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

NOT: Rationale: The milk let-down reflex is caused by the hormone oxytocin.

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