Question 5401)
The nurse is caring for several immediate postpartum women. Which client should
the nurse attend to first?
A. A woman who had a cesarean delivery asks for a drink of water.
B. A woman who had a natural child birth says she needs to urinate.
C. A woman whose baby is nursing says her uterus hurts.
D. A woman says her bed suddenly feels wet beneath her bottom.
Answer: D
Explanation: The woman who reports her bed suddenly feeling wet beneath her bottom may be hemorrhaging. This
needs to be checked out first. The other situations are all probably normal events. The woman who had the
cesarean delivery has been NPO for several hours and is probably thirsty. The woman who had the natural
childbirth may well need to urinate. The baby nursing stimulates oxytocin and uterine contractions.
Question 5402)
The nurse is observing a new mother for good maternal–infant attachment. Which
observation would be a sign of inappropriate attachment?
A. Calling the baby “little bit.”
B. Holding the baby in “en face” position.
C. Telling the baby, “You look just like your daddy.”
D. Continually saying, “I’m too tired to hold the baby.”
Answer: D
Explanation: This may mean she is rejecting the baby. Nicknames, holding the baby in “en face” position (so the
mother can look at the baby’s face), and seeing family resemblance are positive signs of attachment.
Question 5403)
A woman who had a cesarean section tells the nurse, “I guess I flunked natural
childbirth because I had to have a cesarean.” This statement is most indicative of which phase of
postpartum adjustment?
A. Taking in
B. Working through
C. Taking hold
D. Letting go
Answer: A
Explanation: By discussing her experience, she is bringing it into reality. This is characteristic of the taking in
phase. The taking hold phase is when the mother tries to reassert her control of the family, and letting go is when
the baby is integrated into the family. Working through is not one of the phases of postpartum adjustment.
Question 5404)
Six hours after delivery, the nurse notes that a woman’s fundus is two finger
breadths above the umbilicus and deviated to the right of the midline. What is the most likely
cause of this finding?
A. Retained placental fragments
B. Bladder distention
C. Normal involution
D. Second-degree uterine atony
Answer: B
Explanation: Bladder distention causes uterine displacement, which interferes with involution and may lead to
postpartum hemorrhage. With normal involution, the fundus would be at or slightly above the umbilicus and in the
midline. Retained placental fragments and uterine atony would cause excessive bleeding.
Question 5405)
Which area of health teaching will a new mother be most responsive to during the
taking in phase of the postpartum period?
A. Family planning
B. Newborn care
C. Community support groups
D. Perineal care
Answer: D
Explanation: During the taking in phase, the mother is more self-centered. She will be most responsive to perineal
care. She will be most responsive to family planning and newborn care during the taking hold phase. Awareness of
community support groups would be in the taking hold or letting go phases.
Question 5406)
On the first day after a cesarean section, the client is ambulating. She is
uncomfortable and asks the nurse, “Why am I being made to walk so soon after surgery?” What is
the nurse’s best response?
A. “You can get to hold your baby more quickly if you walk around.”
B. “Early walking keeps the blood from pooling in your legs and prevents blood clots.”
C. “Walking early will prevent your wound from opening.”
D. “Early walking helps lower the incidence of wound infection.”
Answer: B
Explanation: Early walking helps to prevent thrombophlebitis. She does not have to walk in order to hold her baby.
Walking does not prevent dehiscence or wound infection.
Question 5407)
A pregnant woman tells the nurse that she is planning to breastfeed because “You
don’t have to take contraceptives until you wean the baby.” What is the best response for the
nurse?
A. “Lactation does suppress ovulation, so you are not likely to get pregnant.”
B. “You will not get pregnant until you start to menstruate again.”
C. “When a woman is breastfeeding, she may not menstruate, although she may ovulate. It is best to use some type
of birth control.”
D. “You will find that you won’t be interested in resuming sexual activity until after you wean the baby.”
Answer: C
Explanation: The bottle-feeding mother’s ovulation and menstrual cycle has been noted to occur as early as 36
days; the breastfeeding mother’s cycle can occur as early as 39 days. Lactation sometimes, but not always,
suppresses ovulation. A nursing mother may ovulate and not menstruate, so another method of contraception is
recommended. Lactation does not have an effect on sexual desire. Breastfeeding is not a reliable method of
contraception.
Question 5408)
A new mother who has been breastfeeding her infant for six weeks calls the nurse
at the doctor’s office and says her right nipple is cracked and sore; she has a temperature and
feels as though she had the flu. How should the nurse respond to the woman?
A. “Try putting warm compresses over your right breast.”
B. “Immediately stop nursing and apply cold compresses to your breasts.”
C. “Come to see the physician. You may need medication to help.”
D. “Reduce the time the baby nurses on your right breast, and call again if the breast is not better in two days.”
Answer: C
Explanation: The data suggest that the mother has mastitis. Antibiotics may be a part of the treatment. She should
be seen by the physician. Warm compresses might be helpful, but the woman needs to be seen by the physician.
Cold compresses are not indicated for infection. She will probably not need to stop nursing or reduce feeding on
that breast.
Question 5409)
At 3 hours of age, a term newborn seems jittery and has a weak and high-pitched
cry and irregular respirations. The nurse suspects that the infant may have which of the following?
A. Hypoglycemia
B. Hypercalcemia
C. Hypervolemia
D. Hypothyroidism
Answer: A
Explanation: Being jittery and having a weak and highpitched cry and irregular respirations are classic symptoms of
hypoglycemia.
Question 5410)
The mother of a newborn is breastfeeding her infant on the delivery table. How
can the nurse best assist her?
A. Touch the infant’s cheek adjacent to the nipple to elicit the rooting reflex
B. Leave the mother and baby alone and allow the infant to nurse as long as desired
C. Position of the Infant to gasp th nipple so as to express milk
D. Give the infant a bottle first to evaluate the baby’s ability to suck
Answer: A
Explanation: The rooting reflex is stimulated when the cheek next to the breast is gently stroked. Answer 2 is not
correct. The nurse should not leave the mother and baby alone until the nurse is confident that mother and baby
are doing well. The infant should not nurse long enough to cause sore nipples. Answer 3 is not correct. The infant
should grasp the areola, not the nipple. Answer 4 is not correct. Giving a bottle first would serve no purpose and
might interfere with nursing.
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