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A nurse is observing a postpartum client interacting with her
newborn and notes that the mother is engaging with the
newborn in the en face position. Which of the following would
the nurse be observing? A) Mother placing the newborn next to
bare breast.
B) Mother making eye-to-eye contact with the newborn
C) Mother gently stroking the newborns face
D) Mother holding the newborn upright at the shoulder -
ANSWER-B The en-face position is characterized by the
mother interacting with the newborn through eye-to-eye
contact while holding the newborn. Bonding is a vital
component of the attachment process for establishing
parent-infant attachment and a healthy, loving relationship.
During this early period of acquaintance, mothers touch their
infants in a characteristic manner. Mothers visually and
physically "explore" their infants, initially using their
fingertips on the infant's face and extremities and
progressing to massaging and stroking the infant with their
fingers. This is followed by palm contact on the trunk.
Eventually, mothers draw their infant toward them and hold the
infant. Kangaroo care refers to skin-to-skin contact between the
mother and newborn.
,When reviewing the medical record of a postpartum client, the
nurse notes that the client has experienced a third-degree
laceration. The nurse understands that the laceration extends
to which of the following?
A) Superficial structures above the muscle
B) Through the perineal muscles
C) Through the anal sphincter muscle
D) Through the anterior rectal wall - ANSWER-C
A third-degree laceration extends through the anal sphincter
muscle. A firstdegree laceration involves only the skin and
superficial structures above the muscle. A second-degree
laceration extends through the perineal muscles. A fourth-
degree laceration continues through the anterior rectal wall
The nurse is assessing a postpartum client's lochia and finds
that there is about a 4-inch stain on the perineal pad. The nurse
documents this finding as which of the following?
A) Scant
B) Light
C) Moderate
D) Large - ANSWER-B
The amount of lochia is described as light or small for an
approximately 4-inch stain. Scant refers to a 1- to 2-inch stain
of lochia; moderate refers to a 4- to 6inch stain; and large or
heavy refers to a pad that is saturated within 1 hour after
changing.
, A nurse is completing a postpartum assessment. Which
finding would alert the nurse to a potential problem? A)
Lochia rubra with a fleshy odor
B) Respiratory rate of 20 breaths per minute
C) Temperature of 101 F
D) Pain rating of 4 on a scale from 0 to 10 - ANSWER-C
Typically, the new mother's temperature during the first 24
hours postpartum is within the normal range. Some women
experience a slight fever, up to 100.4º F (38º C), during the first
24 hours. A temperature above 100.4º F (38º C) at any time or
an abnormal temperature after the first 24 hours may indicate
infection and must be reported. Foul-smelling lochia or lochia
with an unexpected change in color or amount, shortness of
breath, or respiratory rate below 16 or above 20 breaths per
minute would also be a cause for concern. The goal of pain
management is to have the woman's pain scale rating
maintained between 0 to
2 points at all times, especially after
breast-feeding
A nurse is reviewing the medical record of a postpartum client.
The nurse identifies that the woman is at risk for a postpartum
infection based on which of the following? (Select all that
apply.)
A) History of diabetes
B) Labor of 12 hours
C) Rupture of membranes for 16 hours
D) Hemoglobin level 10 mg/dL
E) Placenta requiring manual extraction - ANSWER-A, D, E