Chapter 9 - Test Questions

Leifer: Introduction to Maternity & Pediatric Nursing, 6th Edition Chapter 09: The Family After Birth Test Bank MULTIPLE CHOICE 1. a. b. c. d.

The nurse assessing a newborn recognizes a sign of hypoglycemia, which is: increased nasal mucus. increased temperature. active muscle movements. 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: p. 218 OBJ: 8 TOP: Signs of Hypoglycemia 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: p. 201 OBJ: 2 TOP: Fundus 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. Copyright © 2011 by Saunders, an imprint of Elsevier Inc.

Test Bank

DIF: TOP: KEY: MSC:

9-2

Cognitive Level: Analysis REF: p. 227 OBJ: 14 Breastfeeding—Supplemental Feedings Nursing Process Step: Evaluation NCLEX: Physiological Integrity: Physiological Adaptation

4. Following delivery, the nurse’s assessment reveals a soft, boggy uterus located above the level of the umbilicus. The appropriate intervention is to: 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. DIF: Cognitive Level: Application REF: p. 202 OBJ: 8 TOP: Boggy Uterus KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. a. b. c. d.

The nurse assesses the initial lochia postdelivery, which is known as: serosa. rubra. alba. 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: p. 201 OBJ: 4 TOP: Lochia Rubra 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 that: 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. DIF:

Cognitive Level: Application

REF: p. 202

OBJ: 19

Copyright © 2011 by Saunders, an imprint of Elsevier Inc.

Test Bank

9-3

TOP: Hemorrhage 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: p. 204 OBJ: 2 TOP: Perineal Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 8. The nurse can expect which intervention 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: p. 208 OBJ: 2 TOP: Rubella KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 9. a. b. c. d.

The statement that indicates the new mother is breastfeeding correctly is: “I will put the baby first on the breast that she took last in the previous feeding.” “I keep the baby on a 4-hour feeding schedule.” “I let the baby stay on the first breast only 5 minutes.” “I put only the nipple in the baby’s mouth when I am breastfeeding.”

ANS: A Alternating breasts for feeding increases milk production, particularly hindmilk, which has a higher protein and fat content.

Copyright © 2011 by Saunders, an imprint of Elsevier Inc.

Test Bank

DIF: OBJ: KEY: MSC:

9-4

Cognitive Level: Analysis REF: p. 223, Table 9-3 14 TOP: Breastfeeding Nursing Process Step: Evaluation 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: p. 229 OBJ: 17 TOP: 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: p. 207 OBJ: 4 TOP: Return of Menses 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(n): a. unsensitized Rh-negative mother has an Rh-positive infant. 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 Rhpositive infant. DIF: Cognitive Level: Analysis REF: p. 208 OBJ: 4 TOP: RhoGAM KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of

Copyright © 2011 by Saunders, an imprint of Elsevier Inc.

Test Bank

9-5

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: OBJ: KEY: MSC:

Cognitive Level: Comprehension REF: p. 215, Table 9-2 2 TOP: Thermoregulation Nursing Process Step: Implementation NCLEX: Physiological Integrity: Physiological Adaptation

14. The nurse’s instructions for a new mother to care for the infant’s umbilical cord will include: a. keeping the area covered with a sterile dressing. b. dressing the stump with antibiotic ointment at every diaper change. c. fastening diaper low to allow for air circulation. d. giving the newborn a daily tub bath until the cord falls off. ANS: C Diaper placement below the umbilical stump allows for drying by air circulation. DIF: Cognitive Level: Application REF: p. 218 OBJ: 2 TOP: Umbilical Cord 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 to: 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 TOP: Suppression of Lactation

REF: p. 206 OBJ: 19 KEY: Nursing Process Step: Planning

Copyright © 2011 by Saunders, an imprint of Elsevier Inc.

Test Bank

9-6

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 16. On the second postpartum day, a mother bathed her newborn for the first time. She tells the nurse, “I don’t think I did it right.” Based on the mother’s 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 infant. In doing so, she may become critical of her performance. DIF: OBJ: KEY: MSC:

Cognitive Level: Analysis REF: p. 211, Box 9-1 9 TOP: Postpartum Psychological Stages Nursing Process Step: Assessment 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. “I’ll 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 you’re 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: p. 201 OBJ: 2 TOP: Afterpains with Breastfeeding 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. positioning the bottle so that the nipple is full of formula during the entire feeding. b. heating infant formula in a microwave. c. burping the infant after 4 ounces and again when the bottle is empty. d. propping a bottle for a feeding. ANS: A The nipple of the bottle should be kept full of formula to reduce the amount of air the infant swallows.

Copyright © 2011 by Saunders, an imprint of Elsevier Inc.

Test Bank DIF: OBJ: KEY: MSC:

9-7

Cognitive Level: Comprehension REF: p. 231, Skill 9-7 15 TOP: Formula Feeding Nursing Process Step: Planning NCLEX: Physiological Integrity: Reduction of Risk

19. In the recovery room, the nurse checks the newly delivered woman’s fundus following a cesarean section. How would the nurse proceed with this assessment? a. Palpate from the midline to the side of the 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: p. 210 OBJ: 5 TOP: Postpartum Cesarean Assessment KEY: Nursing Process Step: Assessment 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. “I’ll 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: p. 228 OBJ: 14 TOP: Storing Breast Milk KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 21. For security purposes, when the nurse brings the infant from the nursery to the mother the nurse should: a. ask, “Is this your band number?” b. confirm room number of mother. c. ask the mother to identify herself verbally. d. check the band number of the infant to that of the mother. ANS: D The nurse should check the band number of the infant with that of the mother by asking the mother to verbally read the number.

Copyright © 2011 by Saunders, an imprint of Elsevier Inc.

Test Bank

9-8

DIF: Cognitive Level: Application REF: p. 216 OBJ: 2 TOP: Security Identification Procedure KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 22. The nurse is aware that the newborn is considered hypoglycemic if the blood glucose level is below _____ mg/dL. a. 70 b. 60 c. 50 d. 40 ANS: D A blood glucose level of less than 40 mg/dL is considered hypoglycemic. If the screening sample is below 40 mg/dL a venous sample will be drawn. After the blood has been drawn the infant should be fed to prevent a further drop. DIF: Cognitive Level: Comprehension REF: p. 218 OBJ: 2 TOP: Hypoglycemia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk MULTIPLE RESPONSE 23. Which assessment(s) would lead the nurse to determine the gestational age of the infant as preterm? Select all that apply. a. Thin, transparent skin b. Vernix only in the body creases c. Folded ear springs back slowly d. Breast tissue under the nipple e. Creases over entire sole ANS: A, C The only signs of preterm are the thin skin and the slowly responding ear. DIF: Cognitive Level: Application REF: p. 216 OBJ: 2 TOP: Gestational Age Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 24. The nurse is giving a shower to a patient who had a cesarean section 2 days previously. What intervention(s) should be included before, during, and after the shower? Select all that apply. a. Leave abdominal dressing open to air. b. Position patient with back to water stream. c. Cover infusion site with rubber glove. d. Provide a shower chair. e. Confirm ambulation ability. ANS: B, C, D, E

Copyright © 2011 by Saunders, an imprint of Elsevier Inc.

Test Bank

9-9

The patient should be evaluated for ambulatory ability, and the abdominal dressing and infusion site should be covered with a waterproof cover. The patient should be provided a shower chair and positioned with her back to the water stream. DIF: Cognitive Level: Application REF: p. 210 OBJ: 5 TOP: Postpartum Shower KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 25. What postpartum exercise(s) should the nurse teach a patient who had a vaginal delivery yesterday? Select all that apply. a. Abdominal tighteners b. Head lift c. Pelvic tilt d. Kegel exercises e. Leg lifts ANS: A, B, C, D Exercises for postpartum involution such as abdominal tighteners, head lifts, pelvic tilts, and Kegel exercises are acceptable. Leg lifts are too strenuous early in postpartum period. DIF: Cognitive Level: Comprehension REF: p. 208 OBJ: 19 TOP: Postpartum Exercises KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 26. While instructing a new mother on formula preparations, what type(s) would the nurse include? Select all that apply. a. Ready-to-feed formula b. Concentrated liquid formula c. Powdered formula d. Cow’s 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 infant’s needs, and powdered formula that is mixed as needed. Cow’s milk and canned evaporated milk are unsuitable because they are nutritionally inadequate and stress the kidneys. DIF: Cognitive Level: Comprehension REF: p. 230 OBJ: 15 TOP: Formula Choices KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development COMPLETION 27. The nurse assesses a 6-inch stain of lochia rubra on a pad that was worn for 2 hours. The nurse would document this as a(n) ________________ amount of lochia.

Copyright © 2011 by Saunders, an imprint of Elsevier Inc.

Test Bank

9-10

ANS: moderate A 6-inch stain on a pad worn for 2 hours is regarded as a moderate amount of lochia discharge. DIF: OBJ: KEY: MSC:

Cognitive Level: Application REF: p. 202, Skill 9-2 2 TOP: Estimating Lochia Discharge Nursing Process Step: Assessment NCLEX: Physiological Integrity: Reduction of Risk

28. The nurse explains that the three infections that are contraindications to breastfeeding are _______________, _______________, and ________________. ANS: human immunodeficiency virus (HIV), hepatitis B, hepatitis C Mothers who are HIV positive should not breastfeed because the virus can be transmitted through breast milk, as can the viruses that cause hepatitis B and C. DIF: Cognitive Level: Comprehension REF: p. 222 OBJ: 11 TOP: Contraindication for Breastfeeding KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 29. The hormone responsible for milk production is ____________________. ANS: prolactin During pregnancy, the woman secretes high levels of prolactin, the hormone that causes milk production. Following delivery, increased levels of prolactin lead to lactation. DIF: Cognitive Level: Knowledge REF: p. 222 OBJ: 12 TOP: Prolactin KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation 30. The hormone responsible for milk “let-down” or ejection from the breasts is ____________. ANS: oxytocin The milk “let-down” reflex is caused by the hormone oxytocin. DIF: Cognitive Level: Knowledge REF: p. 222 OBJ: 12 TOP: Oxytocin KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation

Copyright © 2011 by Saunders, an imprint of Elsevier Inc.