A nurse is making an initial call on a new mother who gave birth to her third baby 5 days ago.
The woman says, "I just feel so down this time. Not at all like when I had my other babies. And
this one just doesn't sleep. I feel so inadequate." What is the best response to this new mother?
"Every baby is different with their own temperament. Maybe this one just isn't ready to sleep
when you want him to."
"It sounds like you have the 'baby blues.' They are common after having a baby when you are not
getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the
birth. They will most likely go away in a day or two."
"It sounds like you need to make an appointment with a counselor. You may have postpartum
depression."
"Tell me, are you seeing things that aren't there, or hearing voices?" correct answers "It sounds
like you have the 'baby blues'. They are common after having a baby when you are not getting
enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth.
They will most likely go away in a day or two."
The nurse is doing discharge teaching with the parents of a baby. It is their second child. The
nurse explains about sibling regression and offers ways to deal with regressive behavior. What is
this called?
reinforcement
anticipatory guidance
preparatory instructions
parenting suggestions correct answers Anticipatory guidance
Identification of appropriate psychological adaptations to the postpartum period is necessary to
detect maladaptive behaviors. Which behavior would indicate the need for further assessment of
a new mother's adaptation?
tentative fingertip touching immediately after delivery
staring off into the distance while holding the newborn
calling the infant by the name of the older sibling
staring into the baby's eyes correct answers Staring off into the distance while holding the
newborn
During the assessment, the nurse observes a separation of the rectus muscle that is more than two
fingerbreadths wide. Which instruction should the nurse offer the client?
Perform regular exercises.
Avoid lifting heavy objects.
Sleep on a firm mattress.
Avoid sleeping on back. correct answers Avoid lifting heavy objects
A nurse is caring for a non-breastfeeding client in the postpartum period. The client reports
engorgement. What suggestion should the nurse provide to alleviate breast discomfort?
Apply warm compresses.
Wear a well-fitting bra.
Express milk frequently.
, Apply hydrogel dressing. correct answers Wear a well-fitting bra
A nurse is caring for a client on the second day postpartum. The client informs the nurse that she
is voiding a large volume of urine frequently. Which factor should the nurse identify as a
potential cause for urinary frequency?
urinary overflow
postpartum diuresis
urinary tract infection
trauma to pelvic muscles correct answers Postpartum diuresis
An adolescent primipara was cautious at first when holding and touching her newborn. She
seemed almost afraid to make contact with the baby and only touched it lightly and briefly.
However, 48 hours after the birth, the nurse now notices that the new mother is pressing the
newborn's cheek against her own and kissing her on the forehead. The nurse recognizes these
actions as:
attachment.
engrossment.
involution.
engorgement. correct answers Attachment
A new mother is concerned because it is 24 hours after birth and her breasts have still not
become engorged with breast milk. How should the nurse respond to this concern?
"It takes about 3 days after birth for milk to begin forming."
"I'm sorry to hear that. There are some excellent formulas on the market now, so you will still be
able to provide for your infant's nutritional needs."
"You may have developed mastitis. I'll ask the primary care provider to examine you."
"You are experiencing lactational amenorrhea. It may be several weeks before your milk comes
in." correct answers "It takes about 3 days after birth for milk to begin forming."
The nurse assesses a postpartum client's discharge as being moderate in amount and red in color.
How should the nurse document the appearance of the lochia?
lochia alba
lochia rubra
lochia serosa
lochia normalia correct answers lochia rubra
The nurse is assessing the fundus of a client on postpartum day 2. What should the nurse expect
when palpating the fundus?
fundus 4 cm above symphysis pubis and firm
fundus height 4 cm below umbilicus and midline
fundus two fingerbreadths below umbilicus and firm
fundus two fingerbreadths above symphysis pubis and hard correct answers fundus two
fingerbreadths below umbilicus and firm
A postpartum client is experiencing painful hemorrhoids. Which position should the nurse
suggest the client use when resting?