 A 3-day postpartum client was asking her nurse of what are the common feeding problems.

Which of the following is NOT a complication of breastfeeding?

Chloasma
 A newborn was not dried completely after birth. This places the infant at risk for which of the
following types of heat loss?
Evaporation
 A nurse in a postpartum unit is instructing a mother regarding lochia and the amount of
expected lochia drainage. The nurse instructs the mother that the normal amount of lochia may
vary but should never exceed to which of the following number of pads per day?
Eight perineal pads per day
 A nurse in the delivery room is planning to promote parent-infant bonding for a client who just
delivered. Which of the following is the priority action by the nurse?
Position the neonate skin-to-skin in the client's chest.
 A nurse is assessing a client in the 4th stage of labor and notes that the fundus is firm but severe
bleeding is observed. The immediate nursing action would be which of the following?
Notify the physician
 A nurse is caring for a client who is 1 day postpartum. The nurse is assessing for maternal
adaptation and parent-infant bonding. Which of the following behaviors by the client indicates a
need for the nurse to intervene?
Demonstrates apathy when the newborn cries
 A nurse is caring for a client who is postpartum. The nurse should identify which of the following
findings as an early indicator of hypovolemia caused by hemorrhage?
Increasing pulse and decreasing blood pressure
 A nurse is caring for a newborn immediately following birth. Which of the following nursing
interventions is the highest priority?
Covering the newborn's head with a cap
 A nurse is caring for a newborn. Which of the following actions by the newborn indicates
readiness to feed?
Attempts to place their hand in their mouth
 A nurse is giving instructions to a parent about how to breastfeed their newborn. Which of the
following actions by the parent indicates understanding of the teaching?
When latched on, the infant's nose, cheek, and chin are touching the breast.
 A nurse is preparing to administer a vitamin K (phytonadione) injection to a newborn. Which of
the following responses should the nurse make to the newborn's parent regarding why this
medication is given?
"It assists with blood clotting."
 A nurse is preparing to administer prophylactic eye ointment to a newborn to prevent
ophthalmia neonatorum. Which of the following medications should the nurse anticipate
administering?
Erythromycin
 A nurse is preparing to assess the uterine fundus of a client immediately after delivery of the
placenta. When the nurse locates the fundus, she notes that the uterus feels soft and relax.
Which of the following nursing interventions would be most appropriate initially?
Massage the fundus until it is firm
 A nurse is preparing to perform a fundal assessment on a postpartum client. The initial nursing
action in performing this assessment is which of the following?
Ask the mother to urinate and empty her bladder
 A nurse is providing education to a client who is 2-hour postpartum and has perineal laceration.
Which of the following information should the nurse include?
Use a perineal squeeze bottle to cleanse the perineum.
 Sit on the perineum while resting in bed.
Apply a topical anesthetic cream or spray to the perineum.
Wipe the perineum thoroughly with a back-and-forth motion.
Apply cold or ice packs to the perineum.
1, 3, 5
 A nurse is providing instructions to a mother who has been diagnosed with mastitis. Which of
the following statements if made by the mother indicates a need for further teaching?
"I need to continue breastfeeding until this condition resolves."
 A nurse is reviewing breastfeeding positions with the parent of a newborn. Which of the
following positions should the nurse discuss?
Cradle
 A nurse is taking a newborn to a parent following a circumcision. Which of the following actions
should the nurse take for security purposes?
Match the parent's identification band with the newborn's band.
 A nurse is teaching a client who is breastfeeding and has mastitis. Which of the following
responses should the nurse make?
"Completely empty each breast at each feeding or use a pump."
 A post partum client is to be monitored closely because of history of Episiotomy post delivery.
Which of the following are signs and symptoms to be assessed when observing the episiotomy
area?
All of the above
 A postpartum client is not showing positive indications of parent-infant bonding. However,
when asked if her newborn can be cuddled by other parent, she began appearing very anxious
and nervous . Which of the following actions should the nurse use to promote parent-infant
bonding?
Provide education about infant care preferably when both your client and her husband is
present.
 A postpartum nurse is preparing to care for a woman who has just delivered a healthy newborn
infant. In the immediate postpartum period the nurse plans to take which of the following
woman's vital signs?
Every 15 minutes during the first hour and then every 30 minutes for the next two hours.
 After the birth of a newborn involution of the reproductive organs occur. Which of the following
factors greatly affect the process?
Prolonged labor and difficult birth
 All of the following are important in the immediate care of the premature neonate. Which of the
following nursing activity should have the greatest priority?
Placement in a warm environment
 All of the following are important in the immediate care of the small-for gestational age
neonate. Which nursing activity should have the greatest priority?
Placement in a warm environment
 As part of the postpartum assessment, the nurse examines the breasts of a breastfeeding
woman who is 1-2 days postpartum. An expected finding would be which of the following?
Swollen, warm, and tender upon palpation
 Baby Keanu has a 1-minute Apgar score of 6. What should you do?
Do nothing unless the 5-minute Apgar score has not improved.
 Baby N had an Apgar score of 8 at 1 minute, and 10 at 5 minutes. The Apgar scores are
accurately assessed when the baby's condition which of the following?
Good
 During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood
that soon stops. On assessment, a nurse finds the uterus to be firm, midline, and at the level of
the umbilicus. Which of the following findings should the nurse interpret this data as being?
A normal postural discharge of lochia
 Immediately after birth the nurse notes the following on a male newborn: respirations 78; apical
hearth rate 160 BPM, nostril flaring; mild intercostal retractions; and grunting at the end of
expiration. Which of the following should the nurse do?
Recognize this as normal first period of reactivity
 Perineal care is an important infection control measure. The nurse evaluating a postpartum
client recognizes which of the following actions by the client indicates a need for further
instruction?
Uses the peribottle to rinse upward into her vagina
 The nurse assesses the postpartum vaginal discharge (lochia) on four clients. Which of the
following assessments would warrant notification of the physician?
A bright red discharge 5 days after delivery
 What type of milk is present in the breasts 7 to 10 days PP?
Transitional milk
 Which of the following actions would be least effective in maintaining a neutral thermal
environment for the newborn?
Placing crib close to nursery window for family viewing
 Which of the following behaviors characterizes the postpartum client in the "taking in" phase?
Passive and dependent
 Which of the following factors is NOT related to postpartum hemorrhage?
Placental expulsion
 Which of the following findings would be a source of concern if noted during the assessment of
a woman who is 12 hours postpartum?
Pain in left calf with dorsiflexion of left foot
 Which of the following is NOT a benefit of breastfeeding?
Same with powdered milk, it equally gives same nutritional benefits
 Which of the following measures is NOT helpful in preventing puerperal infection?
May have coitus even if episiotomy its not healed & lochia is present
 Which of the following nursing activities in the care of both the mother and child WOULD NOT
require the standard infection control precautions?
 None of the above
 Which of the following statements is NOT an advantage to breastfeeding?
There is delayed in the return to pre-pregnancy weight in mothers of breastfed infants.