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A mother and her newborn have just been transferred to the postpartum unit from labor and delivery. Which infant safety education would be provided as soon as mom and baby are settled into their room? Select all that apply. One, some, or all responses may be correct.

“Wash your hands before touching the newborn"

"All client identification bands should remain in place until discharge."

"Do not let anyone remove the infant from your sight while you are in the hospital."

"Check the identification of staff, and if there is a question of validity, call the nursing station."

"Send the newborn to nursery to be monitored during the night."

Answer and Explanation

Correct Answer : A,B,C,D

A. Hand hygiene is crucial to prevent the spread of infections to the newborn.

B. Keeping identification bands on ensures proper identification of the newborn.

C. Keeping the infant within sight reduces the risk of abduction.

D. Verifying staff identification enhances security and prevents unauthorized individuals from handling the newborn.
E. Sending the newborn to the nursery at night may compromise the mother-infant bonding and is not a recommended practice.

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Correct Answer is A

Explanation

A. Assessing for respiratory distress is the priority as the newborn's ability to breathe independently is crucial immediately after birth.
B. Acrocyanosis is a common and expected finding in newborns, especially in the first few hours after birth.
C. Accidental lacerations, while important to assess, are not as immediately critical as respiratory distress.
D. While hypothermia is a concern, addressing respiratory distress takes precedence in the immediate postoperative period.

A. Document the findings and continue to monitor the client. B. Encourage the client to empty her bladder. C. Increase the frequency of fundal massage. D. Notify the client’s provider.

Correct Answer is A

Explanation

A. The presence of lochia rubra with small clots in the immediate postpartum period is expected. The firm and midline fundus indicates appropriate uterine contraction. Continued monitoring is appropriate.
B. Encouraging the client to empty her bladder is a valid intervention, but it is not the priority in this situation.
C. Increasing the frequency of fundal massage is unnecessary, as the fundus is already firm.
D. Notifying the provider is not necessary based on the described findings, as they are within the expected range.

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A mother and her newborn have just been transferred to the postpartum unit from labor and delivery. Which infant safety education would be provided as soon as mom and baby are settled into their room? Select all that apply. One, some, or all responses may be correct.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse’s priority?

Correct Answer is A

Explanation

A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client’s perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

What are the most common causes for subinvolution of the uterus?

A nurse on the labor and delivery unit is caring for a newborn immediately following birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn?

While evaluating the reflexes of a newborn, the nurse notes that with a loud noise the newborn symmetrically abducts and extends his arms, his fingers fan out and form a C with the thumb and forefinger, and he has a slight tremor. The nurse would document this finding as a positive reflex.

A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

The nurse is cognizant of which information related to the administration of vitamin K?

A nurse is assessing a newborn 1 hr after birth. Which of the following respiratory rates is within the expected reference range for a newborn?

A nurse is reinforcing teaching about newborn care with a postpartum client. Which of the following statements by the client indicates a need for further teaching?