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?

The baby sleeps with the mother in bed.

The windows are covered with screens.

The kitchen has a refrigerator.

The baby has a changing area.

Answer and Explanation

The Correct Answer is A

The baby sleeps with the mother in bed. This is because sleeping with the baby in the same bed increases the risk of sudden infant death syndrome (SIDS), suffocation, strangulation, and entrapment. The nurse should have assessed the mother’s sleeping arrangements for the baby and provided education on safe sleep practices before discharge. The nurse should advise the mother to place the baby on a firm surface, such as a crib or bassinet, in the same room but not in the same bed as the mother.

Choice B is wrong because having windows covered with screens is not a sign of inadequate home assessment. Screens can help prevent insects and other animals from entering the home and posing a health hazard.

Choice C is wrong because having a refrigerator in the kitchen is not a sign of inadequate home assessment. A refrigerator can help store food and breast milk safely and prevent spoilage and contamination.

Choice D is wrong because having a changing area for the baby is not a sign of inadequate home assessment. A changing area can help keep the baby clean and comfortable and prevent diaper rash and infection.

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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. The Moro reflex was elicited. B. This is abnormal for a full-term infant. C. There may be an abnormality in the musculoskeletal system. D. The full-term infant should not react to sudden movement.

Correct Answer is A

Explanation

The Moro reflex was elicited. This is because the Moro reflex is a normal newborn reflex that occurs when the baby is startled by a loud noise or a sudden movement. The baby responds by extending the arms and legs, opening the hands, and then bringing the arms and legs back to the chest.

The Moro reflex is present at birth and disappears by 3 to 6 months of age.

Choice B is wrong because this is not abnormal for a full-term infant. The Moro reflex is a sign of a healthy nervous system and brain development.

Choice C is wrong because there is no evidence of an abnormality in the musculoskeletal system. The Moro reflex does not indicate any problems with the bones or muscles of the baby.

Choice D is wrong because the full-term infant should react to sudden movement. The Moro reflex is a protective response that helps the baby cling to the mother in case of danger.

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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?

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

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:

Correct Answer is A

Explanation

A nurse is collecting data from a client who delivered 2 hours ago. The client has moderate lochia rubra, temperature within normal limits, breasts soft, fundus firm, slightly deviated to the right, pulse rate 88/min, respiratory rate 18/min. Which of the following actions should the nurse perform?

A nurse is reviewing the medical record of a client who experienced a vaginal birth 2 hr ago. The nurse should identify which of the following findings places the client at risk for a postpartum hemorrhage.

What is the primary rationale for monitoring a new mother every 15 minutes for the first hour after delivery?

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?

The nurse assesses a boggy uterus with the fundus above the umbilicus and deviated to the side. The nurse should next assess:

To protect newborns from infection while in the nursery, the nurse plans 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?