!
!
!
!
!
1. The nurse is assessing a newborn. What sign of hypoglycemia does the nurse record?
!
a. Increased nasal mucus
! b. Increased temperature
! c. Active muscle movements
! d. High-pitched cry
! ANS: D
! There are many signs of hypoglycemia in the newborn. One is a high-pitched cry.
! DIF: Cognitive Level: Comprehension REF: Page 219 OBJ: 9
! TOP: Signs of Hypoglycemia KEY: Nursing Process Step: Data Collection
! MSC: NCLEX: Physiological Integrity: Reduction of Risk
!
2. What would the nurse expect to find when assessing the fundus of the uterus
! immediately after delivery?
! a. Well-contracted with its upper border at or just below the umbilicus
! b. Well-contracted with its upper border three or four fingerbreadths above the umbilicus
! c. Relaxed with its upper border level with the umbilicus
! d. Relaxed with its upper border two or three fingerbreadths below the umbilicus
! ANS: A
Immediately after the placenta is expelled, the uterine fundus can be felt as a firm mass,
!
about the size of a grapefruit, at the level of the umbilicus.
!
! DIF: Cognitive Level: Comprehension REF: Page 200 OBJ: 2
! TOP: Fundus Assessment KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
!
! 3. What statement made by a new mother indicates she needs additional information about
! breastfeeding?
! a. I let the baby nurse 10 to 15 minutes on the first breast and then switch to the other
! breast.
b. The baby needs to nurse at least 5 minutes on the breast to get the hindmilk.
! c. The baby has been nursing every 2 to 3 hours.
! d. If the baby gets fussy between feedings, I give her a bottle of water.
! ANS: D
! Supplemental feedings of formula or water should not be offered to a healthy newborn who
! is breastfeeding.
! DIF: Cognitive Level: Comprehension REF: Page 223-227
! OBJ: 14 TOP: BreastfeedingSupplemental Feedings
! KEY: Nursing Process Step: Evaluation
! MSC: NCLEX: Physiological Integrity: Physiological Adaptation
! 4. After delivery, the nurses assessment reveals a soft, boggy uterus located above the
! level of the umbilicus. What is the most appropriate nursing intervention?
! a. Notify the physician.
! b. Massage the fundus.
! c. Initiate measures that encourage voiding.
! d. Position the patient flat.
ANS: B
! A poorly contracted uterus should be massaged until firm to prevent hemorrhage.
!
!
!
!
!
,!
!
!
!
!
DIF: Cognitive Level: Application REF: Page 202 OBJ: 9
!
TOP: Boggy Uterus KEY: Nursing Process Step: Implementation
! MSC: NCLEX: Physiological Integrity: Physiological Adaptation
!
! 5. What type of lochia will the nurse assess initially after delivery?
! a. Serosa
b. Rubra
! c. Alba
! d. Vaginalis
! ANS: B
! The initial vaginal discharge after delivery is called lochia rubra. It is red and moderately
! heavy. Lochia rubra lasts for up to 3 days postpartum.
! DIF: Cognitive Level: Knowledge REF: Page 202 OBJ: 4
! TOP: Lochia Rubra KEY: Nursing Process Step: Implementation
! MSC: NCLEX: Physiological Integrity: Physiological Adaptation
!
6. A woman will be discharged 48 hours after a vaginal delivery. When planning discharge
! teaching, the nurse would include what information about lochia?
! a. Lochia should disappear 2 to 4 weeks postpartum.
! b. It is normal for the lochia to have a slightly foul odor.
! c. A change in lochia from pink to bright red should be reported.
! d. A decrease in flow will be noticed with ambulation and activity.
! ANS: C
A return to bright red lochia rubra may indicate a late postpartum hemorrhage and must be
!
reported.
!
! DIF: Cognitive Level: Application REF: Page 203 OBJ: 18
! TOP: Hemorrhage KEY: Nursing Process Step: Planning
! MSC: NCLEX: Physiological Integrity: Physiological Adaptation
! 7. What instruction should the nurse teach the postpartum woman about perineal self-care?
! a. Perform perineal self-care at least twice a day.
! b. Cleanse with warm water in a squeeze bottle from front to back.
! c. Remove perineal pads from the rectal area toward the vagina.
d. Use cool water to decrease edema of the perineum.
!
ANS: B
! Cleansing from front to back prevents contamination from the rectal area.
!
! DIF: Cognitive Level: Application REF: Page 204 OBJ: 2
TOP: Perineal Care KEY: Nursing Process Step: Implementation
!
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of
! Disease
!
! 8. A postpartum woman is not immune to rubella. What will the nurse expect?
! a. The rubella virus vaccine should be administered before discharge.
b. The woman should receive the rubella virus vaccine at her 6-week postpartum checkup.
!
c. The woman should be instructed not to get pregnant until she receives the rubella
! vaccine.
! d. No intervention is indicated at this time because the woman is not at risk for rubella.
! ANS: A
!
!
!
!
,!
!
!
!
!
The woman who is not immune to rubella is immunized in the immediate postpartum period
!
because there is no danger of her being pregnant.
!
! DIF: Cognitive Level: Comprehension REF: Page 209 OBJ: 2
! TOP: Rubella KEY: Nursing Process Step: Planning
! MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of
Disease
!
! 9. Which statement indicates the new mother is breastfeeding correctly?
! a. I will alternate breasts when feeding the baby.
! b. I keep the baby on a 4-hour feeding schedule.
c. I let the baby stay on the first breast only 5 minutes.
!
d. I put only the nipple in the babys mouth when I am breastfeeding.
! ANS: A
! Alternating breasts for feeding increases milk production, particularly hindmilk, which has a
! higher protein and fat content.
!
DIF: Cognitive Level: Comprehension REF: Page 224, Table 9-4
! OBJ: 14 TOP: Breastfeeding
! KEY: Nursing Process Step: Evaluation
! MSC: NCLEX: Physiological Integrity: Physiological Adaptation
!
10. The nurse is counseling a lactating mother about diet. What would the nurse include
!
with this information?
! a. Consume 500 more calories than her usual prepregnancy diet.
! b. Eat less meat and more fruits and vegetables.
! c. Drink 3 to 4 tall glasses of fluid daily.
! d. Eat 1000 more calories than her usual prepregnancy diet.
! ANS: A
! To maintain nutrient stores while breastfeeding, the mother needs 500 additional calories
each day over her prepregnancy diet.
!
! DIF: Cognitive Level: Comprehension REF: Page 230 OBJ: 15
! TOP: BreastfeedingMaternal Nutrition
! KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
!
! 11. A woman asks about resumption of her menstrual cycle after childbirth. What should the
! nurse respond?
! a. A woman will not ovulate in the absence of menstrual flow.
b. Most nonlactating women resume menstruation about 2 months postpartum.
! c. Generally, a woman does not ovulate in the first few cycles after childbirth.
! d. The return of menstruation is delayed when a woman does not breastfeed.
! ANS: B
! Menstrual periods resume in about 6 to 8 weeks if the woman is not breastfeeding.
!
DIF: Cognitive Level: Comprehension REF: Page 205 OBJ: 4
! TOP: Return of Menses KEY: Nursing Process Step: Implementation
! MSC: NCLEX: Physiological Integrity: Physiological Adaptation
!
!
!
!
!
!
, !
!
!
!
!
12. In what situation will the physician order RhoGAM?
!
a. An unsensitized Rh-negative mother has an Rh-positive infant.
! b. An Rh-negative mother becomes sensitized.
! c. A sensitized infant has a rising bilirubin level.
! d. An unsensitized infant exhibits no outward signs.
! ANS: A
! The Rh-negative woman should receive RhoGAM within 72 hours after the birth of an Rh-
! positive infant.
! DIF: Cognitive Level: Analysis REF: Page 209 OBJ: 4
! TOP: RhoGAM KEY: Nursing Process Step: Implementation
! MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of
! Disease
! 13. After birth, the nurse quickly dries and wraps the newborn in a blanket. How does this
! action prevent heat loss?
! a. Conduction
! b. Radiation
c. Evaporation
!
d. Convection
!
ANS: C
! Newborns lose heat quickly after birth as fluid evaporates from their bodies.
!
! DIF: Cognitive Level: Comprehension REF: Page 216, Table 9-3
OBJ: 2 TOP: Thermoregulation
!
KEY: Nursing Process Step: Implementation
! MSC: NCLEX: Physiological Integrity: Physiological Adaptation
!
! 14. What will the nurses instructions for a new mother to care for the infants umbilical cord
! include?
a. Keeping the area covered with a sterile dressing
! b. Dressing the stump with antibiotic ointment at every diaper change
! c. Fastening the diaper low to allow for air circulation
! d. Giving the newborn a daily tub bath until the cord falls off
! ANS: C
! Diaper placement below the umbilical stump allows for drying by air circulation.
! DIF: Cognitive Level: Application REF: Page 218-219, Skill 9-6
! OBJ: 2 TOP: Umbilical Cord Care
! KEY: Nursing Process Step: Implementation
! MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of
! Disease
! 15. A new mother states her preference to formula feed her newborn. What will the nurse
! planning discharge instructions tell her to help suppress lactation and promote comfort?
! a. Wear a well-fitting bra continuously for several days.
! b. Stand in a warm shower, letting the water spray over the breasts.
! c. Express small amounts of milk from the breasts several times a day.
d. Massage the breasts when they ache.
! ANS: A
!
!
!
!
!
!
!
!
!
1. The nurse is assessing a newborn. What sign of hypoglycemia does the nurse record?
!
a. Increased nasal mucus
! b. Increased temperature
! c. Active muscle movements
! d. High-pitched cry
! ANS: D
! There are many signs of hypoglycemia in the newborn. One is a high-pitched cry.
! DIF: Cognitive Level: Comprehension REF: Page 219 OBJ: 9
! TOP: Signs of Hypoglycemia KEY: Nursing Process Step: Data Collection
! MSC: NCLEX: Physiological Integrity: Reduction of Risk
!
2. What would the nurse expect to find when assessing the fundus of the uterus
! immediately after delivery?
! a. Well-contracted with its upper border at or just below the umbilicus
! b. Well-contracted with its upper border three or four fingerbreadths above the umbilicus
! c. Relaxed with its upper border level with the umbilicus
! d. Relaxed with its upper border two or three fingerbreadths below the umbilicus
! ANS: A
Immediately after the placenta is expelled, the uterine fundus can be felt as a firm mass,
!
about the size of a grapefruit, at the level of the umbilicus.
!
! DIF: Cognitive Level: Comprehension REF: Page 200 OBJ: 2
! TOP: Fundus Assessment KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
!
! 3. What statement made by a new mother indicates she needs additional information about
! breastfeeding?
! a. I let the baby nurse 10 to 15 minutes on the first breast and then switch to the other
! breast.
b. The baby needs to nurse at least 5 minutes on the breast to get the hindmilk.
! c. The baby has been nursing every 2 to 3 hours.
! d. If the baby gets fussy between feedings, I give her a bottle of water.
! ANS: D
! Supplemental feedings of formula or water should not be offered to a healthy newborn who
! is breastfeeding.
! DIF: Cognitive Level: Comprehension REF: Page 223-227
! OBJ: 14 TOP: BreastfeedingSupplemental Feedings
! KEY: Nursing Process Step: Evaluation
! MSC: NCLEX: Physiological Integrity: Physiological Adaptation
! 4. After delivery, the nurses assessment reveals a soft, boggy uterus located above the
! level of the umbilicus. What is the most appropriate nursing intervention?
! a. Notify the physician.
! b. Massage the fundus.
! c. Initiate measures that encourage voiding.
! d. Position the patient flat.
ANS: B
! A poorly contracted uterus should be massaged until firm to prevent hemorrhage.
!
!
!
!
!
,!
!
!
!
!
DIF: Cognitive Level: Application REF: Page 202 OBJ: 9
!
TOP: Boggy Uterus KEY: Nursing Process Step: Implementation
! MSC: NCLEX: Physiological Integrity: Physiological Adaptation
!
! 5. What type of lochia will the nurse assess initially after delivery?
! a. Serosa
b. Rubra
! c. Alba
! d. Vaginalis
! ANS: B
! The initial vaginal discharge after delivery is called lochia rubra. It is red and moderately
! heavy. Lochia rubra lasts for up to 3 days postpartum.
! DIF: Cognitive Level: Knowledge REF: Page 202 OBJ: 4
! TOP: Lochia Rubra KEY: Nursing Process Step: Implementation
! MSC: NCLEX: Physiological Integrity: Physiological Adaptation
!
6. A woman will be discharged 48 hours after a vaginal delivery. When planning discharge
! teaching, the nurse would include what information about lochia?
! a. Lochia should disappear 2 to 4 weeks postpartum.
! b. It is normal for the lochia to have a slightly foul odor.
! c. A change in lochia from pink to bright red should be reported.
! d. A decrease in flow will be noticed with ambulation and activity.
! ANS: C
A return to bright red lochia rubra may indicate a late postpartum hemorrhage and must be
!
reported.
!
! DIF: Cognitive Level: Application REF: Page 203 OBJ: 18
! TOP: Hemorrhage KEY: Nursing Process Step: Planning
! MSC: NCLEX: Physiological Integrity: Physiological Adaptation
! 7. What instruction should the nurse teach the postpartum woman about perineal self-care?
! a. Perform perineal self-care at least twice a day.
! b. Cleanse with warm water in a squeeze bottle from front to back.
! c. Remove perineal pads from the rectal area toward the vagina.
d. Use cool water to decrease edema of the perineum.
!
ANS: B
! Cleansing from front to back prevents contamination from the rectal area.
!
! DIF: Cognitive Level: Application REF: Page 204 OBJ: 2
TOP: Perineal Care KEY: Nursing Process Step: Implementation
!
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of
! Disease
!
! 8. A postpartum woman is not immune to rubella. What will the nurse expect?
! a. The rubella virus vaccine should be administered before discharge.
b. The woman should receive the rubella virus vaccine at her 6-week postpartum checkup.
!
c. The woman should be instructed not to get pregnant until she receives the rubella
! vaccine.
! d. No intervention is indicated at this time because the woman is not at risk for rubella.
! ANS: A
!
!
!
!
,!
!
!
!
!
The woman who is not immune to rubella is immunized in the immediate postpartum period
!
because there is no danger of her being pregnant.
!
! DIF: Cognitive Level: Comprehension REF: Page 209 OBJ: 2
! TOP: Rubella KEY: Nursing Process Step: Planning
! MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of
Disease
!
! 9. Which statement indicates the new mother is breastfeeding correctly?
! a. I will alternate breasts when feeding the baby.
! b. I keep the baby on a 4-hour feeding schedule.
c. I let the baby stay on the first breast only 5 minutes.
!
d. I put only the nipple in the babys mouth when I am breastfeeding.
! ANS: A
! Alternating breasts for feeding increases milk production, particularly hindmilk, which has a
! higher protein and fat content.
!
DIF: Cognitive Level: Comprehension REF: Page 224, Table 9-4
! OBJ: 14 TOP: Breastfeeding
! KEY: Nursing Process Step: Evaluation
! MSC: NCLEX: Physiological Integrity: Physiological Adaptation
!
10. The nurse is counseling a lactating mother about diet. What would the nurse include
!
with this information?
! a. Consume 500 more calories than her usual prepregnancy diet.
! b. Eat less meat and more fruits and vegetables.
! c. Drink 3 to 4 tall glasses of fluid daily.
! d. Eat 1000 more calories than her usual prepregnancy diet.
! ANS: A
! To maintain nutrient stores while breastfeeding, the mother needs 500 additional calories
each day over her prepregnancy diet.
!
! DIF: Cognitive Level: Comprehension REF: Page 230 OBJ: 15
! TOP: BreastfeedingMaternal Nutrition
! KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
!
! 11. A woman asks about resumption of her menstrual cycle after childbirth. What should the
! nurse respond?
! a. A woman will not ovulate in the absence of menstrual flow.
b. Most nonlactating women resume menstruation about 2 months postpartum.
! c. Generally, a woman does not ovulate in the first few cycles after childbirth.
! d. The return of menstruation is delayed when a woman does not breastfeed.
! ANS: B
! Menstrual periods resume in about 6 to 8 weeks if the woman is not breastfeeding.
!
DIF: Cognitive Level: Comprehension REF: Page 205 OBJ: 4
! TOP: Return of Menses KEY: Nursing Process Step: Implementation
! MSC: NCLEX: Physiological Integrity: Physiological Adaptation
!
!
!
!
!
!
, !
!
!
!
!
12. In what situation will the physician order RhoGAM?
!
a. An unsensitized Rh-negative mother has an Rh-positive infant.
! b. An Rh-negative mother becomes sensitized.
! c. A sensitized infant has a rising bilirubin level.
! d. An unsensitized infant exhibits no outward signs.
! ANS: A
! The Rh-negative woman should receive RhoGAM within 72 hours after the birth of an Rh-
! positive infant.
! DIF: Cognitive Level: Analysis REF: Page 209 OBJ: 4
! TOP: RhoGAM KEY: Nursing Process Step: Implementation
! MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of
! Disease
! 13. After birth, the nurse quickly dries and wraps the newborn in a blanket. How does this
! action prevent heat loss?
! a. Conduction
! b. Radiation
c. Evaporation
!
d. Convection
!
ANS: C
! Newborns lose heat quickly after birth as fluid evaporates from their bodies.
!
! DIF: Cognitive Level: Comprehension REF: Page 216, Table 9-3
OBJ: 2 TOP: Thermoregulation
!
KEY: Nursing Process Step: Implementation
! MSC: NCLEX: Physiological Integrity: Physiological Adaptation
!
! 14. What will the nurses instructions for a new mother to care for the infants umbilical cord
! include?
a. Keeping the area covered with a sterile dressing
! b. Dressing the stump with antibiotic ointment at every diaper change
! c. Fastening the diaper low to allow for air circulation
! d. Giving the newborn a daily tub bath until the cord falls off
! ANS: C
! Diaper placement below the umbilical stump allows for drying by air circulation.
! DIF: Cognitive Level: Application REF: Page 218-219, Skill 9-6
! OBJ: 2 TOP: Umbilical Cord Care
! KEY: Nursing Process Step: Implementation
! MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of
! Disease
! 15. A new mother states her preference to formula feed her newborn. What will the nurse
! planning discharge instructions tell her to help suppress lactation and promote comfort?
! a. Wear a well-fitting bra continuously for several days.
! b. Stand in a warm shower, letting the water spray over the breasts.
! c. Express small amounts of milk from the breasts several times a day.
d. Massage the breasts when they ache.
! ANS: A
!
!
!
!
!
