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The nurse performs the first assessment upon the client's arrival to the postpartum unit.
Where would the nurse expect to palpate the fundus?
a. 3 cm above the umbilicus.
b. 1 cm above the umbilicus.
c. To the right of the umbilicus.
d. Midway between the umbilicus and the pubic bone. - ANSWER b. 1 cm above the
umbilicus.
For the first 12 hours, the fundus should be 1 to 2 cm above the umbilicus
Fifteen minutes after the initial assessment, the nurse finds the client disoriented and lying
on her back in a pool of vaginal blood, with the sheets beneath her saturated with blood.
Which action is most important for the nurse to implement immediately?
a. Take vital signs
b. Massage the fundus
c. Check the bladder
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,d. Increase the IV rate - ANSWER b. Massage the fundus.
Since a boggy fundus is the most likely reason for this client's hemorrhaging, massing the
fundus is the most important intervention. The nurse should also call for assistance due to
the amount of blood that has pooled under the client.
what is the most likely reason a postpartum patient would be hemorrhaging? -
ANSWER uterine atony (a "boggy" fundus)
What should be assessed immediately after fundus is massaged and nurse has called for
help? - ANSWER Assess for bladder distention
--> The client is 2 hours post-delivery with an IV infusion at 125 mL/hour, which can
contribute to diuresis. A distended bladder impedes uterine contraction and contributes to
excessive bleeding. After the fundus is massaged, the bladder should be checked for
distention.
When the nurse conducts a gestational age assessment, which findings may indicate
postmaturity? (Select all that apply. One, some, or all options may be correct.)
a. Testes descended, good rugae.
b. Formed ears with instant recall.
c. Peeling, parchment-like skin.
d. Thin with loose skin and little subcutaneous fat.
e. Deep creases at the base of the toes extending to the heels. - ANSWER c. d. and e.
2
,c. Peeling, parchment-like skin.
d. Thin with loose skin and little subcutaneous fat.
--> Subcutaneous fat, which had been used for nourishment, is lost prior to birth. This
results in the infant's low temperature.
e. Deep creases at the base of the toes extending to the heels.
--> Postterm infants develop deep creases on the feet, extending from the base
The infant has a reddish papular rash across his face. How should the nurse respond when
the client asks about the rash?
a. Don't worry about it. This rash will go away in a couple of days.
b. I see you are concerned, so I will call your pediatrician.
c. A newborn rash is very common, but it will disappear soon.
d. Good question. Let me take the infant's vital signs and examine him - ANSWER c. A
newborn rash is very common, but it will disappear soon.
--> The infant rash, erythema toxicum, is very common and usually disappears by the third
day of life.
3
, Which factor should alert the nurse to assess for the risk of jaundice? -
ANSWER trauma at birth
what is a normal bilirubin range for a newborn? - ANSWER 5-6 mg/dL
Which instructions should the nurse include in the discharge planning regarding the infant's
jaundice?
a. The phototherapy blanket is placed over the infant's clothing.
b. Holding the infant does not interrupt the phototherapy process.
c. A phototherapy blanket is more effective than the overhead lights.
d. The length of time required for phototherapy intervention is decreased. -
ANSWER b. Holding the infant does not interrupt the phototherapy process.
--> Although diapers can be worn, the blanket is placed next to the skin on the trunk of the
body to expose as much skin as possible to the light.
--> The phototherapy blanket allows the infant to be held while the process is continued.
A client in her first trimester is concerned about how weight gain will affect her appearance
and questions the nurse concerning dietary restrictions. How much weight gain should the
nurse point out will be safe for this client with a low BMI? - ANSWER 28 to 40 pounds
The recommendation for average weight gain is 25 to 35 lbs (11 to 16 kilograms).
The woman who is underweight with a low BMI should gain 28 to 40 pounds (13 to 18
kilograms).
Individuals with a high BMI should gain 15 to 25 pounds (7 to 11 kilograms).
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The nurse performs the first assessment upon the client's arrival to the postpartum unit.
Where would the nurse expect to palpate the fundus?
a. 3 cm above the umbilicus.
b. 1 cm above the umbilicus.
c. To the right of the umbilicus.
d. Midway between the umbilicus and the pubic bone. - ANSWER b. 1 cm above the
umbilicus.
For the first 12 hours, the fundus should be 1 to 2 cm above the umbilicus
Fifteen minutes after the initial assessment, the nurse finds the client disoriented and lying
on her back in a pool of vaginal blood, with the sheets beneath her saturated with blood.
Which action is most important for the nurse to implement immediately?
a. Take vital signs
b. Massage the fundus
c. Check the bladder
1
,d. Increase the IV rate - ANSWER b. Massage the fundus.
Since a boggy fundus is the most likely reason for this client's hemorrhaging, massing the
fundus is the most important intervention. The nurse should also call for assistance due to
the amount of blood that has pooled under the client.
what is the most likely reason a postpartum patient would be hemorrhaging? -
ANSWER uterine atony (a "boggy" fundus)
What should be assessed immediately after fundus is massaged and nurse has called for
help? - ANSWER Assess for bladder distention
--> The client is 2 hours post-delivery with an IV infusion at 125 mL/hour, which can
contribute to diuresis. A distended bladder impedes uterine contraction and contributes to
excessive bleeding. After the fundus is massaged, the bladder should be checked for
distention.
When the nurse conducts a gestational age assessment, which findings may indicate
postmaturity? (Select all that apply. One, some, or all options may be correct.)
a. Testes descended, good rugae.
b. Formed ears with instant recall.
c. Peeling, parchment-like skin.
d. Thin with loose skin and little subcutaneous fat.
e. Deep creases at the base of the toes extending to the heels. - ANSWER c. d. and e.
2
,c. Peeling, parchment-like skin.
d. Thin with loose skin and little subcutaneous fat.
--> Subcutaneous fat, which had been used for nourishment, is lost prior to birth. This
results in the infant's low temperature.
e. Deep creases at the base of the toes extending to the heels.
--> Postterm infants develop deep creases on the feet, extending from the base
The infant has a reddish papular rash across his face. How should the nurse respond when
the client asks about the rash?
a. Don't worry about it. This rash will go away in a couple of days.
b. I see you are concerned, so I will call your pediatrician.
c. A newborn rash is very common, but it will disappear soon.
d. Good question. Let me take the infant's vital signs and examine him - ANSWER c. A
newborn rash is very common, but it will disappear soon.
--> The infant rash, erythema toxicum, is very common and usually disappears by the third
day of life.
3
, Which factor should alert the nurse to assess for the risk of jaundice? -
ANSWER trauma at birth
what is a normal bilirubin range for a newborn? - ANSWER 5-6 mg/dL
Which instructions should the nurse include in the discharge planning regarding the infant's
jaundice?
a. The phototherapy blanket is placed over the infant's clothing.
b. Holding the infant does not interrupt the phototherapy process.
c. A phototherapy blanket is more effective than the overhead lights.
d. The length of time required for phototherapy intervention is decreased. -
ANSWER b. Holding the infant does not interrupt the phototherapy process.
--> Although diapers can be worn, the blanket is placed next to the skin on the trunk of the
body to expose as much skin as possible to the light.
--> The phototherapy blanket allows the infant to be held while the process is continued.
A client in her first trimester is concerned about how weight gain will affect her appearance
and questions the nurse concerning dietary restrictions. How much weight gain should the
nurse point out will be safe for this client with a low BMI? - ANSWER 28 to 40 pounds
The recommendation for average weight gain is 25 to 35 lbs (11 to 16 kilograms).
The woman who is underweight with a low BMI should gain 28 to 40 pounds (13 to 18
kilograms).
Individuals with a high BMI should gain 15 to 25 pounds (7 to 11 kilograms).
4
