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An expectant father tells the nurse he fears that his wife is "losing her mind." He states that
she is constantly rubbing her abdomen and talking to the baby and that she actually
reprimands the baby when it moves too much. Which recommendation should the nurse
make to this expectant father?
A.Suggest that his wife seek professional counseling to deal with her symptoms.
B.Explain that his wife is exhibiting ambivalence about the pregnancy.
C. Ask him to report similar abnormal behaviors at the next prenatal visit.
D.Reassure him that normal maternal-fetal bonding is occurring. - ANSWER D)
Reassure him that normal maternal-fetal bonding is occurring.
Rationale: These behaviors are positive signs of maternal-fetal bonding and do not reflect
ambivalence. No intervention is needed.
The nurse is preparing a laboring client for an amniotomy. Immediately after the procedure
is completed, it is most important for the nurse to obtain which information?
A.Maternal blood pressure
B.Maternal temperature
C.Fetal heart rate (FHR)
D.White blood cell count (WBC) - ANSWER C) Fetal heart rate (FHR)
Rationale: The FHR should be assessed before and after the procedure to detect changes
that may indicate the presence of cord compression or prolapse. An amniotomy (artificial
rupture of membranes [AROM]) is used to stimulate labor when the condition of the cervix
is favorable. The fluid should be assessed for color, odor, and consistency.
A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery. In
developing a plan of care, the nurse should give the highest priority to which finding?
1
,A.Cyanosis of the hands and feet
B.Skin color that is slightly jaundiced
C.Tiny white papules on the nose or chin
D.Red patches on the cheeks and trunk - ANSWER B) Skin color that is slightly
jaundiced
Rationale: Jaundice, a yellow skin coloration, is caused by elevated levels of bilirubin, which
should be further evaluated in a newborn <24 hours old.
A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is
prescribed. Which instruction should the nurse provide to this client?
A.Breastfeed the infant, ensuring that both breasts are completely emptied.
B.Feed expressed breast milk to avoid the pain of the infant latching onto the infected
breast.
C.Breastfeed on the unaffected breast only until the mastitis subsides.
D.Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the infant.
- ANSWER A) Breastfeed the infant, ensuring that both breasts are completely
emptied.
Rationale: Mastitis, caused by plugged milk ducts, is related to breast engorgement, and
breastfeeding during mastitis facilitates the complete emptying of engorged breasts,
eliminating the pressure on the inflamed breast tissue.
A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day
tells the nurse that her feet have begun to swell. Which instruction will aid in the prevention
of pooling of blood in the lower extremities?
A.Wear support stockings.
B.Reduce salt in the diet.
C.Move about every hour.
D.Avoid constrictive clothing. - ANSWER C) Move about every hour.
Rationale: Pooling of blood in the lower extremities results from the enlarged uterus
exerting pressure on the pelvic veins. Moving about every hour will relieve pressure on the
pelvic veins and increase venous return.
2
, Twenty-four hours after admission to the newborn nursery, a full-term male infant develops
localized swelling on the right side of his head. In a newborn, what is the most likely cause of
this accumulation of blood between the periosteum and skull that does not cross the suture
line?A.Cephalhematoma, which is caused by forceps trauma
B.Subarachnoid hematoma, which requires immediate drainage
C.Molding, which is caused by pressure during labor
D.Subdural hematoma, which can result in lifelong damage - ANSWER A)
Cephalhematoma, which is caused by forceps trauma
Rationale: Cephalhematoma, a slight abnormal variation of the newborn, usually arises
within the first 24 hours after delivery. Trauma from delivery causes capillary bleeding
between the periosteum and skull.
Prior to discharge, what instructions should the nurse give to parents regarding the
newborn's umbilical cord care at home?
A.Wash the cord frequently with mild soap and water.
B.Cover the cord with a sterile dressing.
C.Allow the cord to air-dry as much as possible.
D.Apply baby lotion after the baby's daily bath - ANSWER C) Allow the cord to air-dry
as much as possible.
Rationale: Recent studies have indicated that air drying or plain water application may be
equal to or more effective than alcohol in the cord healing process.
A mother expresses fear about changing the infant's diaper after circumcision. What
information should the nurse include in the teaching plan?
A.Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours.
B.Wash off the yellow exudate on the glans once every day to prevent infection.
C.Place petroleum ointment around the glans with each diaper change and cleansing.
D.Apply pressure by squeezing the penis with the fingers for 5 minutes if bleeding occurs. -
ANSWER C) Place petroleum ointment around the glans with each diaper change and
cleansing.
3
An expectant father tells the nurse he fears that his wife is "losing her mind." He states that
she is constantly rubbing her abdomen and talking to the baby and that she actually
reprimands the baby when it moves too much. Which recommendation should the nurse
make to this expectant father?
A.Suggest that his wife seek professional counseling to deal with her symptoms.
B.Explain that his wife is exhibiting ambivalence about the pregnancy.
C. Ask him to report similar abnormal behaviors at the next prenatal visit.
D.Reassure him that normal maternal-fetal bonding is occurring. - ANSWER D)
Reassure him that normal maternal-fetal bonding is occurring.
Rationale: These behaviors are positive signs of maternal-fetal bonding and do not reflect
ambivalence. No intervention is needed.
The nurse is preparing a laboring client for an amniotomy. Immediately after the procedure
is completed, it is most important for the nurse to obtain which information?
A.Maternal blood pressure
B.Maternal temperature
C.Fetal heart rate (FHR)
D.White blood cell count (WBC) - ANSWER C) Fetal heart rate (FHR)
Rationale: The FHR should be assessed before and after the procedure to detect changes
that may indicate the presence of cord compression or prolapse. An amniotomy (artificial
rupture of membranes [AROM]) is used to stimulate labor when the condition of the cervix
is favorable. The fluid should be assessed for color, odor, and consistency.
A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery. In
developing a plan of care, the nurse should give the highest priority to which finding?
1
,A.Cyanosis of the hands and feet
B.Skin color that is slightly jaundiced
C.Tiny white papules on the nose or chin
D.Red patches on the cheeks and trunk - ANSWER B) Skin color that is slightly
jaundiced
Rationale: Jaundice, a yellow skin coloration, is caused by elevated levels of bilirubin, which
should be further evaluated in a newborn <24 hours old.
A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is
prescribed. Which instruction should the nurse provide to this client?
A.Breastfeed the infant, ensuring that both breasts are completely emptied.
B.Feed expressed breast milk to avoid the pain of the infant latching onto the infected
breast.
C.Breastfeed on the unaffected breast only until the mastitis subsides.
D.Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the infant.
- ANSWER A) Breastfeed the infant, ensuring that both breasts are completely
emptied.
Rationale: Mastitis, caused by plugged milk ducts, is related to breast engorgement, and
breastfeeding during mastitis facilitates the complete emptying of engorged breasts,
eliminating the pressure on the inflamed breast tissue.
A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day
tells the nurse that her feet have begun to swell. Which instruction will aid in the prevention
of pooling of blood in the lower extremities?
A.Wear support stockings.
B.Reduce salt in the diet.
C.Move about every hour.
D.Avoid constrictive clothing. - ANSWER C) Move about every hour.
Rationale: Pooling of blood in the lower extremities results from the enlarged uterus
exerting pressure on the pelvic veins. Moving about every hour will relieve pressure on the
pelvic veins and increase venous return.
2
, Twenty-four hours after admission to the newborn nursery, a full-term male infant develops
localized swelling on the right side of his head. In a newborn, what is the most likely cause of
this accumulation of blood between the periosteum and skull that does not cross the suture
line?A.Cephalhematoma, which is caused by forceps trauma
B.Subarachnoid hematoma, which requires immediate drainage
C.Molding, which is caused by pressure during labor
D.Subdural hematoma, which can result in lifelong damage - ANSWER A)
Cephalhematoma, which is caused by forceps trauma
Rationale: Cephalhematoma, a slight abnormal variation of the newborn, usually arises
within the first 24 hours after delivery. Trauma from delivery causes capillary bleeding
between the periosteum and skull.
Prior to discharge, what instructions should the nurse give to parents regarding the
newborn's umbilical cord care at home?
A.Wash the cord frequently with mild soap and water.
B.Cover the cord with a sterile dressing.
C.Allow the cord to air-dry as much as possible.
D.Apply baby lotion after the baby's daily bath - ANSWER C) Allow the cord to air-dry
as much as possible.
Rationale: Recent studies have indicated that air drying or plain water application may be
equal to or more effective than alcohol in the cord healing process.
A mother expresses fear about changing the infant's diaper after circumcision. What
information should the nurse include in the teaching plan?
A.Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours.
B.Wash off the yellow exudate on the glans once every day to prevent infection.
C.Place petroleum ointment around the glans with each diaper change and cleansing.
D.Apply pressure by squeezing the penis with the fingers for 5 minutes if bleeding occurs. -
ANSWER C) Place petroleum ointment around the glans with each diaper change and
cleansing.
3
