MATERNITY EXAM 2 - POSTPARTUM,
CARE OF NORMAL NEWBORN
QUESTIONS AND CORRECT ANSWERS
Which of the following muscles would the nurse choose as the preferred site for a
newborn's vitamin K? - Answer-Vastus Laterais.
The nurse is performing an initial assessment of a newborn. Which findings are believed
to be abnormal in the infant? - Answer-Acrocyanosis - bluish discoloration of hands and
feet, Cryptorchidism -undescended testicle , and Hypertonia - too much muscle tone.
The infant developed a caput succedaneum related to the forceps delivery. The parents
are concerned and state that it appears as though the infant has "bled under his scalp."
What information should the nurse provide to the parents? - Answer-It is not blood, but
tissue swelling which will resolve naturally without treatment.
A woman had a vaginal delivery of her second child two days ago. She is breastfeeding
the baby without difficulty. During the postpartum assessment, the nurse would expect
the normal finding of: - Answer-Complaints of afterpains.
Which physiological change takes place during the purerperium? - Answer-The uterus
returns to a pre-pregnant size and location
A newborn not completely dried immediately after delivery losses heat through which of
the following mechanisms of heat loss? - Answer-Evaporation
When caring for a newborn's umbilical cord, a nurse should include which nursing
intervention? - Answer-Keep the cord dry and clean with the diaper folded below it.
A nurse is preparing to bathe a newborn and notices a bluish marking across the
newborn's lower back. What is the significance of this finding? - Answer-The mark is
normal and frequently seen in dark-skinned infants.
When assessing a newborn's mouth, the nurse observes small white nodules on the
roof of the mouth. This finding is characteristic of which condition? - Answer-Epstein's
pearls.
A nurse is assessing a client who is postpartum and exhibiting signs of tearfulness,
insomnia, lack of appetite, and a feeling of letdown. The nurse recognizes these signs
and symptoms are characteristics of: - Answer-Postpartum depression.
A nurse concludes that the father of a newborn is not showing positive signs of parent-
infant bonding and appears to be very anxious and nervous when the infant's mother
, asks him to bring her the infant. Which of the following is an appropriate way to promote
father-infant bonding? - Answer-Provide education about infant are when the father is
present.
Which nursing interventions will promote comfort for a client with an episiotomy? -
Answer--Apply ice to the perineal area for the first 24 to 48 hours.
-Encourage sitz baths at least twice a day.
-Use a topical antiseptic cream or spray on the perineal area.
A nurse is assessing a postpartum client for fundal height, location, and consistency.
The fundus is found to be displaced laterally to the right side and there is uterine atony.
The nurse understands that the most likely cause of the displacement of the uterus and
boggy tone is: - Answer-Poor involution.
The nurse is aware that the most generally accepted theory of the cause of physiologic
jaundice is that it results from: - Answer-Rapid destruction of excess red blood cells.
During ambulation to the bathroom, a postpartum cient experiences a gush of dark red
blood that soon stops. On assessment, the nurse finds the client's uterus to be firm and
midline, at the level of the umbilicus. The nurse interprets this finding as: - Answer-A
normal postural discharge of lochia.
A nurse is performing a fundal assessment on a client in her second postpartum day
and observes the perineal pad for lochia. She notes the pad to be saturated
approximately4.5 inches with lochia that is bright red in color containing small clots and
a fleshy odor. The nurse knows that this finding is: - Answer-Moderate lochia rubra, a
normal finding.
Following delivery, the uterus contracts and gradually returns to it's prepregnant state.
This is referred to as: - Answer-Uterine involution.
A newborn infant's normal apical pulse rate is: - Answer-120 to 160 with a normal sinus
rhythm.
After delivery, the nurse tells the mother that the staff will monitor her carefully for the
first 2 to 4 hours. Which findings should be immediately reported to the RN in charge or
the physician? - Answer-Increased bleeding and a boggy uterus, despite massage.
The nurse massages the uterus of a postpartum patient. Which finding is the best
indication that the intended effect of this nursing action has been achieved? - Answer-
Uterus becomes firm.
The normal respiratory rate for the newborn ranges from? - Answer-30 to 60 breaths per
minute with brief periods of apnea.
CARE OF NORMAL NEWBORN
QUESTIONS AND CORRECT ANSWERS
Which of the following muscles would the nurse choose as the preferred site for a
newborn's vitamin K? - Answer-Vastus Laterais.
The nurse is performing an initial assessment of a newborn. Which findings are believed
to be abnormal in the infant? - Answer-Acrocyanosis - bluish discoloration of hands and
feet, Cryptorchidism -undescended testicle , and Hypertonia - too much muscle tone.
The infant developed a caput succedaneum related to the forceps delivery. The parents
are concerned and state that it appears as though the infant has "bled under his scalp."
What information should the nurse provide to the parents? - Answer-It is not blood, but
tissue swelling which will resolve naturally without treatment.
A woman had a vaginal delivery of her second child two days ago. She is breastfeeding
the baby without difficulty. During the postpartum assessment, the nurse would expect
the normal finding of: - Answer-Complaints of afterpains.
Which physiological change takes place during the purerperium? - Answer-The uterus
returns to a pre-pregnant size and location
A newborn not completely dried immediately after delivery losses heat through which of
the following mechanisms of heat loss? - Answer-Evaporation
When caring for a newborn's umbilical cord, a nurse should include which nursing
intervention? - Answer-Keep the cord dry and clean with the diaper folded below it.
A nurse is preparing to bathe a newborn and notices a bluish marking across the
newborn's lower back. What is the significance of this finding? - Answer-The mark is
normal and frequently seen in dark-skinned infants.
When assessing a newborn's mouth, the nurse observes small white nodules on the
roof of the mouth. This finding is characteristic of which condition? - Answer-Epstein's
pearls.
A nurse is assessing a client who is postpartum and exhibiting signs of tearfulness,
insomnia, lack of appetite, and a feeling of letdown. The nurse recognizes these signs
and symptoms are characteristics of: - Answer-Postpartum depression.
A nurse concludes that the father of a newborn is not showing positive signs of parent-
infant bonding and appears to be very anxious and nervous when the infant's mother
, asks him to bring her the infant. Which of the following is an appropriate way to promote
father-infant bonding? - Answer-Provide education about infant are when the father is
present.
Which nursing interventions will promote comfort for a client with an episiotomy? -
Answer--Apply ice to the perineal area for the first 24 to 48 hours.
-Encourage sitz baths at least twice a day.
-Use a topical antiseptic cream or spray on the perineal area.
A nurse is assessing a postpartum client for fundal height, location, and consistency.
The fundus is found to be displaced laterally to the right side and there is uterine atony.
The nurse understands that the most likely cause of the displacement of the uterus and
boggy tone is: - Answer-Poor involution.
The nurse is aware that the most generally accepted theory of the cause of physiologic
jaundice is that it results from: - Answer-Rapid destruction of excess red blood cells.
During ambulation to the bathroom, a postpartum cient experiences a gush of dark red
blood that soon stops. On assessment, the nurse finds the client's uterus to be firm and
midline, at the level of the umbilicus. The nurse interprets this finding as: - Answer-A
normal postural discharge of lochia.
A nurse is performing a fundal assessment on a client in her second postpartum day
and observes the perineal pad for lochia. She notes the pad to be saturated
approximately4.5 inches with lochia that is bright red in color containing small clots and
a fleshy odor. The nurse knows that this finding is: - Answer-Moderate lochia rubra, a
normal finding.
Following delivery, the uterus contracts and gradually returns to it's prepregnant state.
This is referred to as: - Answer-Uterine involution.
A newborn infant's normal apical pulse rate is: - Answer-120 to 160 with a normal sinus
rhythm.
After delivery, the nurse tells the mother that the staff will monitor her carefully for the
first 2 to 4 hours. Which findings should be immediately reported to the RN in charge or
the physician? - Answer-Increased bleeding and a boggy uterus, despite massage.
The nurse massages the uterus of a postpartum patient. Which finding is the best
indication that the intended effect of this nursing action has been achieved? - Answer-
Uterus becomes firm.
The normal respiratory rate for the newborn ranges from? - Answer-30 to 60 breaths per
minute with brief periods of apnea.
