The nurse has received shift report on the postpartum unit. Which patient should the nurse see first?

First baby, day of delivery, fundus 2 cm above umbilicus deviated to left.

Second baby, first postpartum day, hypoactive bowel sounds all quadrants.

Third baby, first postpartum day, 3 cm diastasis recti abdominis

Second baby, third day post-cesarean, moderate lochia serosa.

Answer and Explanation

The Correct Answer is A

A) First baby, day of delivery, fundus 2 cm above umbilicus deviated to left:
This is the most urgent situation. The fundus should typically be at the level of the umbilicus on the first postpartum day. A fundus that is 2 cm above the umbilicus and deviated to the left may indicate that the bladder is full, which can cause uterine displacement. This is a priority because if the bladder is not emptied, it could lead to uterine atony or hemorrhage. The nurse should first assess the bladder and encourage the client to void, or catheterize if needed, to correct the deviation.

B) Second baby, first postpartum day, hypoactive bowel sounds all quadrants:
Hypoactive bowel sounds on the first postpartum day can be expected, particularly after a cesarean section or due to the effects of medications such as opioids. While this finding should be monitored, it is not as urgent as a potential issue with uterine positioning that could affect bleeding or uterine tone.

C) Third baby, first postpartum day, 3 cm diastasis recti abdominis:
Diastasis recti abdominis, where the abdominal muscles separate, is a common finding postpartum, especially after multiple pregnancies. While it may cause discomfort, it is generally not an immediate concern unless there is significant pain or other complications. It can be addressed with physical therapy over time.

D) Second baby, third day post-cesarean, moderate lochia serosa:
Lochia serosa is the expected discharge 3 days postpartum after a cesarean. Moderate lochia serosa is normal at this stage and does not indicate an immediate problem. The nurse should continue to monitor the lochia, but this is not as urgent as addressing the possible uterine displacement and bladder issue in Option A.

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Correct Answer is E

Explanation

A) Bulb syringe in crib:
While a bulb syringe can be useful for clearing the infant’s airway in case of respiratory distress, keeping it in the crib is not an optimal safety practice. The syringe should be readily available but not within reach of the infant, as it could be a choking hazard if mishandled. Ideally, it should be stored in an easily accessible area but not within the crib.

B) Secure hugs tag on and alarms activated:
Ensuring that the infant has a security tag (often referred to as a "Hugs" tag) that is properly placed and that alarms are activated is an important safety measure to prevent infant abductions. Hospitals typically use electronic security systems that alert staff if the infant is removed from the designated area without proper authorization. This intervention is essential for maintaining safety in the hospital setting.

C) ID bands match with mom's ID bands:
It is critical that the infant's ID band matches the mother's ID band. This helps prevent any mix-up or baby swap and ensures that the infant is properly identified at all times. Regular checks should be made to verify that the bands match and remain secure throughout the hospital stay.

D) Infant on their back to sleep:
Placing the infant on their back to sleep is a key guideline for reducing the risk of Sudden Infant Death Syndrome (SIDS). This position has been proven to be the safest for infants and is a crucial practice for their well-being. Educating parents and caregivers about safe sleep practices is vital for infant safety.

E) All of the above:
All of these practices are part of a comprehensive safety plan for the infant. Ensuring that the infant is safely secured with proper identification, preventing any risk of abduction, promoting safe sleep practices, and ensuring that airway equipment is available are all essential measures in maintaining the safety of the newborn. Therefore, the correct response is "All of the above."

A. Has at least six to eight wet diapers per day B. Sleeps for 6 hours at a time between feedings C. Gains 1 to 2 ounces per week D. Has at least one breast milk stool every 24 hours

Correct Answer is A

Explanation

A) Has at least six to eight wet diapers per day:
One of the most reliable signs of effective breastfeeding is adequate hydration and urine output, which can be assessed by the number of wet diapers. A well-fed infant should have at least six to eight wet diapers per day, indicating that they are taking in sufficient breast milk and are adequately hydrated. This is a key indicator of successful breastfeeding and helps to ensure that the baby is getting enough milk.

B) Sleeps for 6 hours at a time between feedings:
While it is normal for newborns to sleep, they should not go for long periods without feeding, especially in the early days of life. Newborns typically need to be fed every 2 to 3 hours, and a sleep pattern of 6 hours between feedings could be concerning, as it may indicate that the baby is not waking up frequently enough to eat. This could result in inadequate milk intake and dehydration. Breastfeeding on demand is important, and frequent feedings help to stimulate milk production.

C) Gains 1 to 2 ounces per week:
A typical weight gain for a newborn is about 4 to 7 ounces per week during the first few months of life. Gaining 1 to 2 ounces per week could be lower than expected, and while weight gain is an important indicator of breastfeeding effectiveness, it is not the most immediate or reliable sign in the first week, especially if the baby is otherwise feeding well and producing an adequate number of wet diapers.

D) Has at least one breast milk stool every 24 hours:
While it is normal for a newborn to have breast milk stools, the frequency can vary widely. Some infants may pass stools after every feeding, while others may have fewer. One stool every 24 hours is not necessarily a sign of inadequate breastfeeding, especially if the baby is having a good number of wet diapers. The stool pattern can differ from baby to baby, and as long as the infant is feeding well and producing sufficient wet diapers, stool frequency alone is not the best indicator of breastfeeding success.

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The nurse has received shift report on the postpartum unit. Which patient should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is E

Explanation

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Correct Answer is A

Explanation

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