A new mother of a newborn girl calls the clinic in a panic, concerned about the blood-tinged soiled diaper. What is the best response from the nurse?

This can be from the sudden withdrawal of your hormones. It's not a cause for alarm.

The baby may have a problem; let's schedule an appointment.

For now, just watch her. If this continues, call us back.

This can be related to cleaning her perineal area; be more careful.

Answer and Explanation

The Correct Answer is A

This can be from the sudden withdrawal of your hormones. It's not a cause for alarm. This is because newborn female babies may have a little bloody vaginal discharge in their diaper due to the withdrawal of maternal hormones after delivery. This usually stops as the hormones return to normal levels¹².

Choice B is wrong because the baby does not need an appointment for this condition.

Choice C is wrong because the mother does not need to watch her baby for this condition.

Choice D is wrong because the blood is not related to cleaning her perineal area.

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Correct Answer is A

Explanation

Massage the fundus. This is because massaging the fundus (the upper part of the uterus) can help the uterus contract and prevent excessive bleeding after delivery. A soft, boggy uterus indicates uterine atony, which is a failure of the uterus to contract sufficiently after childbirth.

Uterine atony is the most common cause of postpartum hemorrhage, which can be life-threatening if not treated promptly¹².

Choice B is not correct because initiating measures that encourage voiding is not the appropriate intervention for a soft, boggy uterus. A full bladder can interfere with uterine contractions and cause bleeding, so it is important to empty the bladder after delivery. However, this should be done after massaging the fundus.

Choice C is not correct because positioning the patient flat is not the appropriate intervention for a soft, boggy uterus. Positioning the patient flat can increase blood loss and reduce venous return. The patient should be positioned with the head slightly elevated and the legs flexed to improve blood circulation and prevent shock³.

Choice D is not correct because notifying the doctor is not the first intervention for a soft, boggy uterus. Notifying the doctor is important if bleeding persists or worsens despite massaging the fundus. The doctor may order medications or other treatments to stop the bleeding and prevent complications¹.

A. Sucking B. Grasp C. Tonic neck D. Rooting

Correct Answer is D

Explanation

Rooting. The rooting reflex is a primitive neonatal reflex that helps the baby find the breast or bottle to start feeding. When the corner of the baby's mouth is stroked or touched, the baby will turn his or her head and open his or her mouth to follow and root in the direction of the stroking. This reflex lasts about 4 months.

Choice A. Sucking is not the correct answer because it is a different reflex that starts when the roof of the baby's mouth is touched, and it does not help the baby find the breast or bottle.

Choice B. Grasp is not the correct answer because it is a reflex that causes the baby to close his or her fingers in a grasp when the palm of the hand is stroked, and it has nothing to do with breastfeeding.

Choice C. Tonic neck is not the correct answer because it is a reflex that causes the baby to assume a "fencing" position when the head is turned to one side, and it also has nothing to do with breastfeeding.

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A new mother of a newborn girl calls the clinic in a panic, concerned about the blood-tinged soiled diaper. What is the best response from the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Following delivery, the nurse's assessment reveals a soft, boggy uterus located above the level of the umbilicus. The appropriate intervention is:

Correct Answer is A

Explanation

A first-time mother reports that she is experiencing difficulty breastfeeding her newborn. The neonatal reflex that the nurse would teach the mother to elicit, in order to facilitate breastfeeding is:

Correct Answer is D

Explanation

A nurse is caring for a client who is experiencing shaking chills during the immediate postpartum period. Which of the following actions should the nurse take?

A nurse is updating the plan of care for a newborn who is undergoing phototherapy. Which of the following actions should the nurse include in the plan?

A nurse is collecting data from a newborn and notes a swollen area on the head that does not cross the suture line. The nurse should interpret this finding as which of the following?

A nurse is teaching a new mother about signs of effective breastfeeding of her newborn. Which of the following information should the nurse include in the teaching?

The first sign of hypovolemic shock from postpartum hemorrhage is likely to be:

The nurse is conducting a prenatal class explaining the various activities that will occur within the first few hours after birth. The nurse determines the session is successful when the couples correctly choose which reason for the use of an antibiotic ointment.

When the newborn's crib was moved suddenly, the nurse noticed that his legs flexed and the arms fanned out, and then both came back toward the midline. The nurse would interpret this behavior as:

A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client's perineal pad. Which of the following actions should the nurse take first?