Which technique is used to palpate the fundal height on a postpartum client? - ANS place hand
at the base of the uterus, one on the fundus
Which assessment finding indicates to the nurse that a newborn has hip subluxation? - ANS
Inability of the right hip to abduct
The nurse is providing discharge teaching to the postpartum client regarding mood changes to
report. In differentiating between postpartum depression and baby blues what should be
included in the instructions? - ANS Baby blues may present in the first few days after birth and
resolve prior to the second postpartum week.
Hypoglycemia in a mature infant is defined as a blood glucose level below which amount? -
ANS 40-100
The nurse assesses a postpartum client's discharge as being moderate in amount and red in
color. How should the nurse document the appearance - ANS Lochia rubra
By the time children reach their tenth birthday, they should have learned to trust others and
should have developed a sense of what? - ANS industry
The parents of a newborn are concerned that something is wrong with their newborns eyesight.
What should the nurse instruct the parents as being - ANS follows a light to the midline
A nurse is caring for a four year old female. Which of the following is expected of a
preschool-aged child? - ANS relaxing fears to magical thinking
In providing care to the postpartum client the nurse recognizes that women are hypercoagulable
during the 3rd trimester of pregnancy and that assessment of this client should include
evaluation for the development of venous thromoembolism. Which of the following should be
included in this evaluation? - ANS - observe the lower extremities
- Observation of respiratory rate and effort
The nurse has instructed on the importance of providing a toddler with a balanced diet. Which
observation during a home visit indicates that instruction has been effective? - ANS The mother
prepares a scrambled egg for the toddler's breakfast.
The nurse is caring for a postpartum woman 18 hours after primary cesarean section for
preeclampsia. The client is noted to have a boggy and a moderate to large amount of vaginal
bleeding. The nurse notifies the physician of these findings and expects an order for which of
the following medications? - ANS Carboprost
, A nurse is caring for a nine month old with influenza. Which of the following might be a toy that
could be used to interact, play, or distract them from the discomfort? - ANS large plastic stacking
blocks
A nurse is caring for an infant with myelomeningocele. Which of the following actions should the
nurse include in the preoperative plan of care? - ANS apply a sterile, moist dressing on the sac
The nurse is called to the room of a client who delivered a macrosomic infant 20 hours ago.
Upon assessment, the fundus is noted to be boggy and displacement is noted. What is the
priority nursing action? - ANS empty the bladder
The nurse is assessing the breast of a woman who is 1 month postpartum. The woman reports
a painful, inflamed area on one breast. Upon admission, the breast is red and warm to the
touch. The client's temperature is 101.8F. What should the nurse consider at the potential
diagnosis? - ANS Mastitis
The nurse is evaluating a new mother's ability to effectively breastfeed her infant. Which criteria
indicates that the mother should be able to breastfeed independently? - ANS - nipples are
inverted
- breasts are soft and non-tender
- the mother holds the infant close to her breast in a football hold.
- infant swallows spontaneously and frequently
During a home visit, a new mother is concerned that after three meconium stools, her newborn
as yellow seedy stools. - ANS This is a normal finding
A nurse at a well-baby clinic is collecting data about a nine-month infant. The nurse understands
which of the following occurs at this stage of development. - ANS fears strangers
During a home visit, a postpartum client is complaining of a sore area on one breast. The nurse
notes a local on the left breast to be lumpy, red, and warm to the touch and palpates a small
lump. - ANS plugged milk duct
A new mother asks the nurse how soon she can try to breastfeed after delivery. Which of the
following would be the nurses best response? - ANS "immediately after birth"
The nurse is concerned that a new mother is not showing interest in the newborn and does not
participate in newborn care. What action should the nurse take to help both the mother and
newborn at this time? - ANS consult a case manager to complete a post partum assessment
A nurse in a postpartum unit is reviewing uterotonic (oxytocic) medication with a group of
nursing students. Which of the following would be included in this discussion? - ANS Misoprostil
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