Choose the sign or symptom that a new mother should be taught to report:

Occasional uterine cramping when the infant nurses.

Descent of the fundus one fingerbreadth each day.

Reappearance of red lochia after it changes to serous.

Oral temperature that is 37.2 C (99 F) in the morning.

Answer and Explanation

The Correct Answer is C

Choice A reason:

Occasional uterine cramping when the infant nurses is a normal phenomenon that occurs as the uterus contracts and returns to its pre-pregnancy size. This is not a sign of infection or complication and does not need to be reported.

Choice B reason:

Descent of the fundus one fingerbreadth each day is also a normal finding that indicates the uterus is involuting properly. The fundus is the top of the uterus that can be felt through the abdomen. It should be at the level of the umbilicus immediately after delivery and then descend about one fingerbreadth (or 1 cm) each day until it reaches the pelvic brim by 10 days postpartum.

Choice C reason:

Reappearance of red lochia after it changes to serous is an abnormal sign that may indicate uterine atony, subinvolution, or retained placental fragments. Lochia is the vaginal discharge that occurs after childbirth, consisting of blood, mucus, and tissue. It usually changes from red to pink to brown to yellow-white over a period of several weeks. If it becomes red again, it may mean that there is bleeding from the uterus or infection in the endometrium. This should be reported to a health care provider as soon as possible.

Choice D reason:

Oral temperature that is 37.2 C (99 F) in the morning is within the normal range and does not indicate fever or infection. A slight elevation in temperature may occur due to dehydration, breast engorgement, or hormonal changes. This does not need to be reported unless it exceeds 38 C (100.4 F) or persists for more than 24 hours.

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Correct Answer is C

Explanation

The correct answer is: c. The lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth.

Choice A reason:

If this baby was born vaginally, it could indicate a pneumothorax.

A pneumothorax occurs when air leaks into the space between the lung and chest wall, causing the lung to collapse. This condition can happen in newborns, especially those with underlying lung issues or those who have undergone mechanical ventilation However, moist lung sounds in a newborn are not typically indicative of a pneumothorax. Pneumothorax is more likely to present with symptoms such as rapid breathing, grunting, and cyanosis.

Choice B reason:

The neonate must have aspirated surfactant.

Surfactant aspiration is not a common cause of moist lung sounds. Surfactant is a substance that helps keep the lungs’ air sacs open and is crucial for proper lung function. Aspiration of surfactant is not a typical diagnosis and would not usually result in moist lung sounds. Instead, surfactant deficiency or dysfunction can lead to respiratory distress syndrome, which presents differently.

Choice C reason:

The lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth.

Babies born via cesarean section often have moist lung sounds because they do not experience the compression of the chest that occurs during vaginal delivery, which helps expel fluid from the lungs. This retained fluid can cause moist lung sounds, which typically resolve within the first 24 hours after birth. This is a normal finding and does not usually indicate a serious problem.

Choice D reason:

The nurse should notify the pediatrician stat for this emergency situation.

While it is always important to monitor newborns closely, moist lung sounds alone in a baby born via cesarean section are not typically an emergency. This finding is usually due to retained fluid in the lungs, which is expected to clear within the first day of life. Immediate notification of the pediatrician is not necessary unless the baby shows other signs of respiratory distress or other concerning symptoms.

A. The woman had a vacuum-assisted birth. B. The woman is a gravida 2, para 2. C. The woman has an episiotomy. D. The woman received epidural anesthesia.

Correct Answer is C

Explanation

A. The woman had a vacuum-assisted birth. While vacuum-assisted births can cause perineal trauma, the specific orders for ice packs, sitz baths, and stool softeners are more directly related to an episiotomy, which involves a surgical incision that requires careful postpartum care.

B. The woman is a gravida 2, para 2. This information indicates the woman's obstetric history but does not directly correlate with the need for perineal ice packs, sitz baths, and stool softeners. These orders are more specific to perineal trauma or surgical intervention.

C. The woman has an episiotomy. An episiotomy involves a surgical cut made at the opening of the vagina during childbirth, which can cause significant perineal pain and swelling. The orders for perineal ice packs, sitz baths, and stool softeners are intended to manage pain, reduce swelling, and prevent constipation, which can be particularly uncomfortable with perineal stitches.

D. The woman received epidural anesthesia. While epidural anesthesia is a common pain management technique during labor, it does not necessitate the use of perineal ice packs, sitz baths, or stool softeners postpartum. These orders are more indicative of perineal trauma or surgical intervention such as an episiotomy.

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Choose the sign or symptom that a new mother should be taught to report:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago via cesarean section is found to have moist lung sounds. What is the best interpretation of these data?

Correct Answer is C

Explanation

A woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener. What information is most closely correlated with these orders?

Correct Answer is C

Explanation

The priority nursing care associated with an oxytocin (Pitocin) infusion is:

While assisting with a vacuum extraction birth, what should the nurse immediately report to the physician?

After an amniotomy, which action by the nurse takes priority?

A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?

Which newborn reflex elicits the following reaction: Head turns to one side - the way the head is facing, the arm/leg is stretched out while the other is bent?

The nurse understands which condition is a contraindication for an amniotomy.

Erin gives birth to a boy. The nurse notes the following on the baby at 1 minute: heart rate is 138 bpm, loud vigorous crying, spontaneous movement and flexion of the extremities, and pink skin color except for a bluish color of the hands and feet. What Apgar score will be assigned to the baby?

After teaching a pregnant woman about the hormones produced by the placenta, the nurse determines that the teaching was successful when the woman identifies which hormone produced as being the basis for pregnancy tests?