A woman had a vaginal delivery two days ago and is preparing for discharge. To help prevent postpartum complications, the nurse plans to teach the woman to report any:

Change in lochia from red to white

Fatigue and irritability

Fever

Contractions

Answer and Explanation

The Correct Answer is C

Fever. This is because fever is a sign of infection, which is a common and potentially serious postpartum complication. Infection can affect various parts of the body, such as the uterus (endometritis), the bladder (cystitis), the breast (mastitis), the wound (wound infection), or the blood (sepsis). Infection can cause symptoms such as fever, chills, pain, foul-smelling discharge, redness, swelling, or warmth at the site of infection.

Choice A is not correct because the change in lochia from red to white is not a sign of postpartum complication. Lochia is the vaginal discharge that occurs after childbirth. It changes color and amount over time, from red to pink to brown to yellow to white. This is a normal process of healing and does not indicate a problem unless the lochia is foul-smelling, heavy, or contains large clots³.

Choice B is not correct because fatigue and irritability are not signs of postpartum complications. Fatigue and irritability are common feelings after childbirth due to hormonal changes, sleep deprivation, physical recovery, and emotional adjustment. They do not necessarily indicate a problem unless they are severe or persistent and interfere with daily functioning or bonding with the baby.

Choice D is not correct because contractions are not signs of postpartum complication. Contractions are normal after childbirth and help the uterus shrink back to its pre-pregnancy size. They are usually mild and subside within a few days. They may be more intense during breastfeeding due to the release of oxytocin, which stimulates uterine contractions.

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Correct Answer is D

Explanation

Injecting the medication into the vastus lateralis. This is because the vastus lateralis is a large muscle in the thigh that is suitable for intramuscular injections in newborns³. The vitamin K injection helps prevent vitamin K deficiency bleeding, which is a rare but serious condition that can cause bleeding in the brain or other organs¹. The American Academy of Pediatrics recommends that all newborns receive a single intramuscular dose of 0.5 to 1 mg of vitamin K within one hour of birth².

Choice A is wrong because a 21 gauge needle is too large for a newborn's muscle. A 25 or 27 gauge needle is more appropriate.

Choice B is wrong because injecting at a 45-degree angle may not reach the muscle tissue. A 90-degree angle is more appropriate.

Choice C is wrong because injecting 1cc of medication is too much for a newborn's muscle. The recommended dose of vitamin K is 0.5 to 1 mg, which is equivalent to 0.05 to 0.1 mL.

A. Gastroesophageal reflux B. Sudden infant death syndrome C. Apnea episodes D. Sleeping for short intervals

Correct Answer is B

Explanation

Sudden infant death syndrome (SIDS) is the sudden and unexplained death of an infant under one year of age. SIDS is more likely to occur when infants sleep on their stomachs or sides, or when they are propped up with pillows or other soft bedding. These positions can interfere with the infant's breathing and increase the risk of suffocation or overheating .

Choice A is incorrect because gastroesophageal reflux (GER) is a common condition in infants that causes them to spit up frequently after feeding. GER does not increase the risk of SIDS and can be managed by feeding smaller amounts, burping the infant often, and keeping them upright for a while after feeding.

Choice C is incorrect because apnea episodes are brief pauses in breathing that occur normally in infants, especially during sleep. Apnea episodes do not increase the risk of SIDS and usually resolve by six months of age.

Choice D is incorrect because sleeping for short intervals is normal for newborns, who need to feed frequently during the day and night. Sleeping for short intervals does not increase the risk of SIDS and will gradually change as the infant grows older.

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A woman had a vaginal delivery two days ago and is preparing for discharge. To help prevent postpartum complications, the nurse plans to teach the woman to report any:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client?

Correct Answer is D

Explanation

The nurse is caring for a new mother and newborn in a rooming-in unit and watches the mother put the infant in the bed, lying on her side, propped up with a pillow. The nurse should point out that this position can increase the risk of which situation?

Correct Answer is B

Explanation

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?

Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress?

The nurse is visiting a new mother who has been home with a new infant for 4 days. Which observation indicates that the mother's home environment was inadequately assessed prior to being discharged from the hospital?

Parents express concern about the milia on the face and nose of their baby. The nurse's most helpful response would be to instruct the parents to:

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 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.

A nurse is caring for a postpartum client who saturates a perineal pad in 10 minutes. Which of the following actions should the nurse take first?