MCH Mod 1-3 Exam 1 Rev: Ch 20 - 23 (graded for accuracy) 98% Scored with rationales Updated 2025/26.

Exit Performance MCH Mod 1-3 Exam 1 Rev: Ch 20 - 23 (graded for accuracy) Due Jul 8, 2025 by 11:59 pm Final Score 98% 49 out of 50 questions answered correctly Completed on Jul 1, 2025 10:11 am Incorrect (1) Report content errorWhich factor is a common cause of decreased milk production? Select all that apply. One, some, or all responses may be correct. Some correct answers were not selected Rationale Factors contributing to low milk production include prematurity, missed feedings, ineffective suckling, low thyroid function, and oral contraceptives containing estrogen. p. 496 Prematurity Missed feedings Ineffective suckling Maternal hypothyroidism Estrogen containing oral contraception Correct (49) Report content error Which procedure will the nurse follow to identify a newborn's parent? Check the ID band number with the parent’s. Check the ID band number with the delivery record.Rationale The nurse will check the infant's ID band with the parent’s before giving the newborn to the parent. Checking the ID band number with the delivery record does not verify that the parent is wearing the correct identification band. Using the crib card to identify the infant and parent does not guarantee the correct infant has been placed in the correct crib. The infant's ID band on the wrist or ankle must be checked with the ID band that is on the parent. The infant has his or her own medical record number, which is separate from the mother’s; therefore this is not an appropriate way to correctly identify a newborn's parent. Test-Taking Tip: Start by reading each of the answer options carefully. Usually, at least one of them will be clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices by one and improved the odds. Continue to analyze the options. If you can eliminate one more choice in a four-option question, you have reduced the odds to 50/50. While you are eliminating the wrong choices, recall often occurs. One of the options may serve as a trigger that causes you to remember what a few seconds ago had seemed completely forgotten. p. 477 Report content error Use the crib card to identify the infant with the parent. Match the infant’s medical record number with the mother’s.The nurse is providing follow-up care to a patient 3 days after birth. The nurse notes post-birth uterine discharge that is a pinkish-brown color and trickles from the vaginal opening. How does the nurse document this? Rationale Lochia is a post-birth uterine discharge that changes in color and consistency as the body recovers from birth. Lochia serosa is lochia that appears pink or brown 3 or 4 days after birth. It consists of old blood, serum, leukocytes, and tissue debris. Lochia rubra is bright red and consists of blood and decidual and trophoblastic debris, which is present right after birth. The lochia becomes more pale with time. Lochia alba is drainage that becomes yellow to white and occurs 10 to 14 days after birth. It mostly consists of leukocytes, decidua, epithelial cells, mucus, serum, and bacteria. Nonlochial bleeding is bloody discharge that comes from the vagina and is bright red. p. 400 Report content error Lochia alba Lochia rubra Lochia serosa Nonlochial bleedingWhich statement regarding infant weaning is correct? Rationale Weaning is initiated by the mother or the infant. With infant-led weaning, the infant moves at his or her own pace in omitting feedings, which leads to a gradual decrease in the mother's milk supply. Mother-led weaning means that the mother decides which feedings to drop. Infants can be weaned directly from the breast to a cup. Bottles are usually offered to infants less than 6 months. If the infant is weaned before 1 year of age, iron-fortified formula rather than cow's milk should be offered. The feeding of least interest to the baby or the one through which the infant is likely to sleep should be eliminated first. Every few days thereafter the mother drops another feeding. Gradual weaning over a period of weeks or months is easier for both the mother and the infant than an abrupt weaning. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer. p. 502 Report content error Weaning can be mother- or infant-initiated. Abrupt weaning is easier than gradual weaning. Weaning should proceed from breast to bottle to cup. The feeding of most interest should be eliminated first.The nurse examines a 6-day-old newborn and observes that the infant's skin color and sclera appear yellowish. What would the nurse expect to find in the laboratory reports of the infant? Rationale The infant's skin color and sclera of eyes appear yellow caused by jaundice, which is caused by elevated unconjugated (free) bilirubin levels in the serum that is greater than 20 mg/dL (hyperbilirubinemia). Yellowing of the skin, or jaundice, is not caused by abnormal levels of platelets, blood glucose levels, or leukocytes. A platelet count of less than 150,000/mm indicates vitamin K deficiency, which can lead to severe hemorrhage. Blood glucose levels that are less than 40 mg/dL indicate hypoglycemia, and a leukocyte count of less than 12,000/mm indicates that the newborn has sepsis. p. 438 Report content error Why is vitamin K given to the newborn? Platelet count less than 150,000/mm 3 Blood glucose levels less than 40 mg/dL Free bilirubin levels greater than 20 mg/dL Leukocyte count less than 12,000/mm 3 3 3 To reduce bilirubin levelsRationale Vitamin K is required for the production of certain clotting factors. Vitamin K does not reduce bilirubin levels. Vitamin K does not increase the production of red blood cells. Newborns have a deficiency of vitamin K until intestinal bacteria that produce vitamin K are formed. Vitamin K does not stimulate the formation of surfactant. Test-Taking Tip: Answer every question because, on the NCLEX exam, you must answer a question before you can move on to the next question. p. 435 Report content error Which rationale describes the physiologic benefit of providing analgesics to a breastfeeding patient experiencing afterpains? Rationale To increase the production of red blood cells To enhance ability of blood to clot To stimulate the formation of surfactant Facilitates the milk-ejection reflex Stimulates the release of oxytocin Increases maternal milk production Increases the amount of oxytocin releasedThe benefit of analgesics promoting short-term pain relief is that it facilitates the milk-ejection reflex, resulting in the release of milk into the alveoli from the ducts. Oxytocin is released from the posterior pituitary gland during breastfeeding and causes an increase in afterpains. Analgesics do not directly increase maternal milk production. Analgesics do not increase the amount of oxytocin released from the posterior pituitary gland. p. 400 Report content error Which information will the nurse include in the instruction of bottle feeding techniques? Select all that apply. One, some, or all responses may be correct. Rationale When discussing bottle feeding techniques, the nurse will instruct the patient to avoid propping the bottle, as propping the bottle increases the likelihood of choking. The nurse will instruct the patient to use a cradle hold when feeding, which allows the parent to be face-to-face with the infant. The nurse will tell the patient to anticipate feeding the infant every Avoid propping the bottle. Use a cradle hold when feeding. Feed the infant every 3 to 4 hours. Avoid warming the formula in the microwave. Test the temperature of the formula on your inner arm before feeding.3 to 4 hours to provide necessary nutrition. The nurse will instruct the patient to avoid warming the formula in the microwave, because doing so places the infant at risk for a burn injury. The patient would test the temperature of the formula on the inner arm before feeding to decrease the chance of the infant receiving a burn injury. p. 503,pp. 503-504 Report content errorWhich factor will the nurse associate with an increased risk for postpartum hemorrhage? Select all that apply. One, some, or all responses may be correct. Rationale Uterine fibroids and placenta abruptio place the postpartum patient at risk for hemorrhage. Diabetes places the patient at risk for infection. There are no maternal risk factors associated with oligohydramnios. Prolonged rupture of membranes also places the patient at risk for infection. p. 405 Report content error Diabetes Uterine fibroids Placenta abruptio Oligohydramnios Prolonged rupture of membranesA patient gave birth to a 7 lb, 3 oz boy 2 hours ago. The nurse determines that the patient's bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate postpartum period, the most serious consequence likely to occur from bladder distention is what? Rationale Excessive bleeding can occur immediately after birth if the bladder becomes distended because it pushes the uterus up and to the side and prevents it from contracting firmly. A urinary tract infection may result from overdistention of the bladder, but it is not the most serious consequence. A ruptured bladder may result from a severely overdistended bladder. However, vaginal bleeding most likely would occur before the bladder reaches this level of overdistention. Bladder distention may result from bladder wall atony. The most serious concern associated with bladder distention is excessive uterine bleeding. p. 407 Report content error Urinary tract infection Excessive uterine bleeding Ruptured bladder Bladder wall atonyWhich factor contributes to nipple confusion when an infant is both bottle fed and breastfed? Select all that apply. One, some, or all responses may be correct. Rationale The mouth and tongue movements are different in breastfeeding and bottle feeding. The same thrusting tongue movement an infant uses sucking from a bottle will result in the breast being pushed out of the mouth. While the flow of milk is initially faster in a bottle, this is not associated with nipple confusion. Sucking strength and placement of the nipple in the mouth are not identified factors related to nipple confusion. p. 497 Report content error Which effect may occur in an infant after administering erythromycin 0.5% ophthalmic ointment? Select all that apply. One, some, or all responses may be correct. Flow of milk Sucking strength Mouth movement Tongue movements Placement of the nipple in the mouth BurningRationale Burning, blurred vision, and mild inflammation may occur in an infant after administration of erythromycin 0.5% ophthalmic ointment. Purulent discharge is a clinical finding associated with infection. Erythromycin 0.5% ophthalmic ointment does not cause a discoloration of the sclera. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer. p. 470 Report content error Which guideline is associated with the administration of vitamin K to a newborn? Blurred vision Mild inflammation Purulent discharge Discoloration of the sclera Vitamin K can be given orally. Vitamin K is administered immediately after delivery. Vitamin K should be given within an hour after delivery. The administration of vitamin K can be deferred if the infant feeds well.Rationale One dose of vitamin K is administered intramuscularly within the first hour after birth to prevent bleeding problems until the infant can produce vitamin K independently. Oral vitamin K is not as effective as vitamin K administered intramuscularly. The administration of vitamin K generally occurs within 1 hour after birth, regardless of the infant feeding well. p. 470 Report content error Which technique would the nurse use when obtaining an infant’s measurements? Rationale The infant's length is measured from the top of the head to the heal of an outstretched leg. The weight of the infant is obtained at birth and then daily after that until discharged from the unit. The chest is measured at the level of the nipples. The diameter of the infant's head is measured around the occiput and just above the eyebrows. p. 451 Weigh the infant at birth and before discharge. Measure the chest slightly above the nipple line. Measure the head from around the occiput and below the eyebrows. Measure the length from the top of the head to the heal of an outstretched leg.Report content error Which infant activity would the nurse include when discussing early cues to initiate breastfeeding? Select all that apply. One, some, or all responses may be correct. Rationale Lip smacking indicates the infant is ready for feeding. Increased activity and hand-to-mouth movements are other signs for which the infant is ready to feed. Crying is a late sign of hunger. A crying infant must be calmed before he or she is ready to feed. A quiet alert state is not a sign of hunger. p. 492 Report content error Crying Quiet alert Lip smacking Increased activity Hand-to-mouth movementsThe nurse is reviewing the record of a patient who stopped smoking during her pregnancy. Which factor will the nurse determine is associated with an increased risk for relapse? Select all that apply. One, some, or all responses may be correct. Rationale Factors that increase the risk of relapse include bottle feeding, a spouse that smokes, bipolar disorder, and the stress of full-time employment. A medical condition such as type 1 diabetes is not specifically associated with relapse in smoking. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation. p. 418-419 Report content error Bottle feeding Spouse smokes Bipolar disorder Type 1 diabetes Full-time employmentWhich information would the nurse include when providing patient education that focuses on the suppression of lactation? Rationale A good-fitting sports bra compresses the breast and interferes with the stimulation of milk production. Analgesics are used for discomfort, not specifically to suppress lactation. Warm towels on the breast and a warm shower promote vasodilation, which contributes to the stimulation of milk production. p. 428,p. 412 Report content error Which activity will the nurse incorporate into the plan of care to help prevent discomfort from abdominal distention after a cesarean section? Administer analgesics. Wear a good-fitting sports bra. Place warm towels on the breast. Take a warm shower. Increase oral fluid intake. Administer a stool softener. Encourage frequent ambulation.Rationale Frequent ambulation can relieve abdominal distention. Increasing oral fluid intake does not relieve abdominal distention. Stool softeners do not relieve abdominal distention. Kegel exercises are used to strengthen the perineal muscles. p. 410 Report content error The nurse notes that a postpartum patient’s fundal exam is u/-1 midline and boggy. Which action will the nurse take if the fundus becomes firm during the massage but becomes boggy when the massage is stopped? Rationale The nurse will apply pressure to express clots that may be accumulating in the uterus, which can cause the uterus to become boggy. There is no indication that the patient's bladder requires emptying. The nurse will notify the health care provider after performing the interventions to firm Provide instruction for Kegel exercises. Empty the patient’s bladder. Attempt to express the clots. Notify the health care provider. Begin an oxytocin the fundus. If there are no clots that are present after an attempt to express them and the fundus remains boggy, the nurse will notify a colleague to communicate the situation to the health care provider. Oxytocin administration is initiated if the nurse is unable to improve the uterine tone. Test-Taking Tip: Once you have decided on an answer, look at the stem again. Does your choice answer the question that was asked? If the question stem asks "why," be sure the response you have chosen is a reason. If the question stem is singular, then be sure the option is singular, and the same for plural stems and plural responses. Many times, checking to make sure that the choice makes sense in relation to the stem will reveal the correct answer. p. 406 Report content error Breastfeeding an infant provides which benefit? Select all that apply. One, some, or all responses may be correct. Rationale Nutrients are well-absorbed. Allergies are less likely to develop. Overfeeding is less likely to occur. Infant mortality is decreased. Immunologic properties help prevent infection.The benefits of breastfeeding for the infant include the fact that the nutrients are well-absorbed, allergies are less likely to develop, the infant is less likely to be overfed, infant mortality is decreased, and the infant receives immunologic properties to help prevent infection. p. 489 Report content error Which action would the nurse take after noting that a postpartum patient's fundus is u/+1 firm but shifted to the right? Rationale The nurse will ask the patient to empty her bladder, and then the nurse will recheck the location of the fundus. A firm fundus does not require massage. The nurse can document the findings after reassessment. There is no indication that the patient has clots. p. 406 Massage the fundus. Document the findings. Ask the patient to empty her bladder. Apply downward pressure to express clots.Report content error Which additional finding would cause concern if, during the initial newborn examination, an infant’s left hand has a single crease parallel with the base of the infant’s fingers that crosses the palm without a break? Select all that apply. One, some, or all responses may be correct. Rationale A single crease parallel with the base of the infant's fingers that crosses the palm without a break is referred to as a simian crease. This feature, together with a low set thumb and incurving little finger, is associated with trisomy 21. Blue discoloration of the palms describes acrocyanosis, which is a common finding after birth. Assessment findings which include a strong palmer grasp and two long transverse palmar creases across the palm are normal. p. 446 Low set thumb Incurving little finger Blue discoloration of both palms Strong palmer grasp in both hands Right hand with two long transverse palmar creases across the palmReport content error Which behavioral state would be expected for a full-term infant shortly after birth? Rationale The full-term newborn is in a quiet alert state shortly after birth. The fullterm infant is not generally drowsy, entering into a light sleep, or actively alert shortly after birth. p. 441 Report content error For which reason will a newborn require administration of vitamin K after birth? Drowsy Quiet alert Light sleep Active alert Immature liver Absence of bacterial flora Inability to metabolize Vitamin KRationale A newborn is unable to synthesize vitamin K in the intestines without bacterial flora and is therefore deficient in clotting factors. A newborn requires an intramuscular vitamin K injection shortly after birth to promote clotting. Although the newborn liver is immature, this is not the reason vitamin K is necessary to promote clotting. Metabolism of vitamin K and an immature gastrointestinal system are not factors associated with the inability to synthesize vitamin K. p. 469 Report content error A postpartum patient states, "I had no idea I would still look pregnant 2 days after delivery." Which response will the nurse provide to address the patient's concern about her appearance? Rationale Immature gastrointestinal system "Your abdominal muscle wall has weakened." "During your pregnancy, a diastasis recti formed." "The uterus takes a few weeks to return to the prepregnant size." "It takes several weeks for your weight to return to a prepregnant state."It is an anticipated finding that the fundus undergoes a period of involution and by the 14th postpartum day is in the pelvic cavity. The shape of the firm fundus causes the appearance of a protruding abdomen, which resembles a pregnancy. Weakened abdominal walls, diastasis recti, or postdelivery weight does not specifically create the appearance of pregnancy. Test-Taking Tip: Attempt to select the answer that is most complete and includes the other answers within it. For example, a stem might read, "A child's intelligence is influenced by what?" and three options might be genetic inheritance, environmental factors, and past experiences. The fourth option might be multiple factors, which is a more inclusive choice and therefore the correct answer. p. 403,pp. 403-404 Report content error The nurse is preparing to assess the perineum of a patient 2 hours postpartum with a second-degree labial laceration. Which position will the nurse place the patient in to evaluate her perineum? Select all that apply. One, some, or all responses may be correct. Supine Side-lying Lithotomy Low Fowler’s Dorsal recumbentRationale The nurse will assess the patient’s labia in a side-lying and dorsal recumbent position. Both the side-lying and dorsal recumbent positions will allow for visualization of labia. A side-lying position will also be used to allow for additional visualization of the perineum and rectal area. The assessment of the perineum is not performed in a supine position, lithotomy, or low Fowler’s position. p. 408 Report content error Which characteristic describes infant formula? Select all that apply. One, some, or all responses may be correct. Rationale The protein in some formula can be treated to be less allergenic. The formula is adapted to correspond with the components in breast milk; however, an exact match is impossible. Modified cow's milk is the source of most formula. Formula can be modified to meet the special needs of infants, such as infants with lactase deficiency, lactose intolerance, Can be treated to be less allergenic Cannot exactly replicate breast milk Sourced mostly by modified cow’s milk Can be modified to meet the special needs of infants Can be concentrated to meet the nutrient needs of the preterm infantphenylketonuria, and malabsorption disorders. Formula can be concentrated to meet the nutrient needs of the preterm infant. pp. 502-503 Report content error Based a newborn's ability to regulate acid-base balance, a newborn is at risk for which acid-base imbalance? Rationale Newborns tend to lose bicarbonate at lower levels than adults, and the lower ability to reabsorb it increases a newborn’s risk for metabolic acidosis. The newborn is not at the most risk for metabolic alkalosis, respiratory acidosis, or respiratory alkalosis. Test-Taking Tip: Start by reading each of the answer options carefully. Usually, at least one of them will be clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices by one and improved the odds. Continue to analyze the options. If you can eliminate one more choice in a four-option question, you have reduced the odds to 50/50. While you are eliminating the wrong choices, recall often occurs. One of the options may serve as a trigger that causes you to remember what a few seconds ago had seemed completely forgotten. Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosisp. 439 Report content error Which function describes the role of carbohydrates in breast milk and their effect on an infant? Select all that apply. One, some, or all responses may be correct. Rationale Carbohydrates in breast milk improve the infant's absorption of calcium, provide energy for brain growth, and prevent the growth of intestinal pathogens. The enzymes in breast milk aid in digestion. Triglycerides help promote the development of the nervous system. p. 488 Report content error Aids in digestion Improves calcium absorption Provides energy for brain growth Prevents the growth of intestinal pathogens Promotes development of the nervous systemWhich instruction will the nurse plan to include in parental teaching about sudden infant death syndrome (SIDS)? Select all that apply. One, some, or all responses may be correct. Rationale SIDS can be prevented by avoiding the use of heavy blankets and avoiding smoking around the baby. A light sleeper will prevent the infant from overheating. Because infants tend to turn their heads toward the center of the room or toward the door, alternating the ends of the crib for sleep is an intervention to help prevent plagiocephaly. Burping the infant after a feeding releases air that may have been swallowed during feeding but is not an intervention directly associated with decreasing the risk of SIDS. p. 480 Report content error A postpartum patient due for a fundal assessment tells the nurse that she is cramping, and her pain is at a 4/10. Which action will the nurse take? Avoid the use of heavy blankets. Avoid smoking around the baby. Place the infant in a light sleeper. Alternate the ends of the crib for sleep. Burp the infant after a feeding before placing the baby in the crib. Assess the maternal vital signs.Rationale Before assessing the fundus, the nurse will ask the patient to empty her bladder if she has not recently voided. The maternal vital signs do not always need to be evaluated before a fundal assessment; vital signs will be affected by the patient's discomfort. The amount of lochia on the peripad is evaluated during a fundal assessment. The nurse will not delay the assessment to wait for the medication to become effective. A fundal assessment is essential in evaluating the physiologic stability of a postpartum patient. Test-Taking Tip: Do not panic while taking an exam! Panic will only increase your anxiety. Stop for a moment, close your eyes, take a few deep breaths, and resume review of the question. p. 402,p. 407 Report content error A patient with a history of gonorrheal infection has just delivered a baby. What immediate intervention should the nurse provide to the newborn to ensure safety? Ask the patient when she last voided. Assess the amount of lochia on the peripad. Defer the assessment until the medication begins working. Administer ophthalmic solution. Place the newborn in incubator. Perform a heelstick puncture test.Rationale The nurse should administer erythromycin ophthalmic solution to the newborn within 2 hours of birth to prevent ophthalmia neonatorum caused by gonorrheal infection. Incubation is preferred in order to regulate the body temperature when a neonate has hypothermia. Heelstick puncture is performed to detect abnormalities in blood levels only if the neonate has any infection. Ventilator support is provided if the neonate's heart rate is below 100 beats per minute. However, the heart rate is not decreased because of a gonorrheal infection. p. 469 Report content error Which risk factor will the nurse attribute to the development of nonphysiologic jaundice in the newborn? Rationale Nonphysiologic jaundice occurs within the first 24 hours. This type of jaundice is a result of abnormalities causing excessive destruction of red Provide ventilator support to the newborn. Prematurity Poor breastfeeding Cephalohematoma Rhesus (Rh) incompatibilityblood cells, such as with Rh incompatibility. Prematurity places the newborn at risk for physiologic jaundice. Poor breastfeeding puts the infant at risk for early-onset jaundice. A cephalohematoma places the newborn at risk for physiologic jaundice. p. 438,pp. 437-438 Report content error Which intervention would be included when planning to discharge a 48-hour-old breastfeeding newborn? Select all that apply. One, some, or all responses may be correct. Rationale When discharging a 48-hour-old breastfed newborn, the nurse will ensure that the infant’s vital signs are stable, evaluate the infant’s elimination pattern, instruct the parent to bring in a car seat, and schedule a follow-up visit with a health care provider for the newborn within 48 to 72 hours after discharge. The newborn must have fed successfully at least twice before discharge; however, the number of feedings is irrelevant if the newborn is not feeding correctly. p. 483 Review the number of feedings. Ensure the vital signs are stable. Evaluate the elimination pattern. Instruct the parent to bring a car seat. Schedule a follow-up visit within 48 to 72 hours after discharge.Report content error Which change occurs during lactogenesis II? Select all that apply. One, some, or all responses may be correct. Rationale During lactogenesis II, transitional milk appears. The fat increases, proteins decrease, and the vitamin content remains unchanged. Calories increase and immunoglobulins decrease during lactogenesis II. p. 487 Report content error Fat increases. Proteins decrease. Calories remain the same. Immunoglobulins increase. Vitamins content remains unchanged.Which teaching technique would be most effective for the nurse to use when providing information to new parents about how to change a diaper? Rationale Demonstration is the most effective teaching method to teach a parent how to change a diaper. A demonstration provides the nurse the opportunity to explain how to prepare for a diaper change safely, discuss handwashing and expected findings, and encourage the parents to ask questions. Audiovisual materials do not allow for nurse-patient interaction during teaching. Not every patient prefers group teaching. Written instructions do not allow for nurse-patient interaction during teaching. p. 482 Report content error Which action would be taken after noting a 12-hour-old infant failed a hearing screening? Audiovisual Demonstration Group teaching Written instruction Notify the health care provider. Refer the parent to an audiologist.Rationale The nurse will repeat the testing before discharge. There is no reason to notify the health care provider or to refer the parent to an audiologist because testing is generally performed twice before discharging the infant home. The initial hearing screening test can be performed at 12 or more hours after birth. p. 483 Report content error Which information will the nurse include when instructing a patient on preparation for the use of bottles? Rationale Repeat the testing before discharge. Disregard the results because of the age when testing was performed. "Use an aseptic method when preparing the bottles." "You can prepare a 48 hour supply of bottles worth of feedings." "Boil the water for 10 minutes before using it to dilute the formula." "Initially sterilize bottles and nipples before using them for the first time."Bottles and nipples would be sterilized before the first use. An aseptic method for formula preparation is necessary if the water supply is questionable. Bottles would be prepared for no longer than 24 hours’ worth of feedings. Water used for formula would be boiled for 1 minute before mixing the formula. p. 503 Report content error Which information will the nurse plan to include when discussing the use and storage of pumped breast milk? Rationale Fresh, unrefrigerated breast milk would be used within 1 hour of pumping. Storage containers should be sterile if the patient is hospitalized. Frozen breast milk would be thawed in a refrigerator or by holding the container under running water. Breast milk can be stored in the refrigerator for 48 hours. pp. 501-502 Store your milk in a sterile container. Frozen breast milk can be thawed at room temperature. Breast milk can be stored in the refrigerator for 24 hours. Fresh, unrefrigerated breast milk would be used with 1 hour of pumping.Report content error Which assessment will the nurse include in the immediate postpartum period for a patient who has received buprenorphine during labor and delivery? Select all that apply. One, some, or all responses may be correct. Rationale Included in the initial assessment of a postpartum patient who has received buprenorphine are vital signs, urinary output, and the IV site. Buprenorphine is an opioid analgesic that does not affect the patient's ability to move the extremities or affect sensation in the lower extremities. p. 409-410,p. 404 Report content error Vital signs Urinary output Intravenous (IV) site Ability to move extremities Sensation in lower extremitiesWhich intervention will the nurse anticipate providing to an infant after a circumcision has been performed using a Gomco? Select all that apply. One, some, or all responses may be correct. Rationale The nurse will evaluate the infant’s pain, apply petroleum jelly to the circumcision site, and administer acetaminophen as prescribed for pain. Sucrose is only used as a nonpharmacologic pain measure during the procedure. A topical anesthetic will only be applied before the procedure. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation. pp. 477-478 Report content error Measure pain. Provide sucrose. Apply petroleum jelly. Administer acetaminophen. Reapplying a topical anesthetic.Which action will the nurse take before placing an infant with an axillary temperature of 97.1°F under a radiant warmer? Rationale To avoid heat loss or overheating the infant, the nurse will check the temperature setting of the radiant warmer to ensure that it is set between 96.8°F and 97.7°F. The infant’s cap must be removed to prevent the transfer of heat to the head before placing the infant under the warmer. The infant would not be wrapped in any blankets or have clothing on other than a diaper while under the warmer. A skin probe will be attached to the infant's abdomen after it has been verified that the temperature of the warmer is within acceptable parameters. p. 471 Report content error Which information will the nurse include when discussing the expression of breast milk with a patient who plans on returning to work? Select all that apply. One, some, or all responses may be correct. Cover the infant’s head with a cap. Wrap the infant in a single warm blanket. Attach a skin probe to the infant’s abdomen. Check the temperature setting of the warmer. Thawed breast milk must be used within 24 hours.Rationale The patient will be instructed that thawed breast milk must be used within 24 hours. Breast pumping will last approximately 10 to 15 minutes per session. The patient should begin pumping her breasts a week or two before returning to work. Once the breastfeeding has been well established, it is important to introduce a bottle of breast milk to help the infant adjust to bottle feeding. The patient will be instructed to begin by pumping once or twice a day to build up a small supply of milk. pp. 501-502 Report content error Which information will the nurse include in the parent teaching for a newborn? Breast pumping will last approximately 10 to 15 minutes per session. Start pumping your breasts a week or two before you return to work. Occasionally introduce a bottle of breast milk to help the infant adjust. Begin by pumping once or twice a day to build up a small supply of milk. Provide stimulation during the active alert phase. After undressing the baby, use a football hold to shampoo the hair.Rationale The nurse would instruct the parents that the baby is not constipated if the baby turns red when passing a stool. Constipated infants pass small, hard stools that are fewer in number than usual. Babies best respond to stimulation during the quiet alert phase. To conserve heat, the infant would remain dressed while getting the hair shampooed. The parents would be instructed to notify the healthcare provider if the infant's temperature is greater than 100.0°F. Test-Taking Tip: Avoid taking a wild guess at an answer. However, should you feel insecure about a question, eliminate the alternatives that you believe are definitely incorrect, and reread the information given to make sure you understand the intent of the question. This approach increases your chances of randomly selecting the correct answer or getting a clearer understanding of what is being asked. Although there is no penalty for guessing, the subsequent question will be based, to an extent, on the response you give to the question at hand; that is, if you answer a question incorrectly, the computer will adapt the next question accordingly based on your knowledge and skill performance on the examination up to that point. pp. 480-481 Report content error The baby is not constipated if the baby turns red when passing a stool. Notify the healthcare provider (HCP) if the infant’s temperature is greater than 102°F.Which statement made by the nurse demonstrates the promotion of paternal adaptation? Select all that apply. One, some, or all responses may be correct. Rationale Encouraging discussion of the paternal role, teaching the father how to pick up the baby, teaching the father how to participate in feeding and general infant care, and providing encouragement and praise all promote paternal adaptation. p. 419-420 Report content error Which assessment finding 4 hours postcircumcision will the nurse report to the healthcare provider (HCP)? "How do you feel about becoming a father?" "Let me show you how to pick up the baby safely." "You are doing an excellent job changing diapers." "You can participate in the infant feeding by burping the baby." "I will be showing you and your wife how to give the baby a bath." Meatitis Hematoma Absent voiding Increased irritabilityRationale A hematoma indicates that the newborn is bleeding and is a postoperative complication for which the healthcare provider needs to be notified. Meatitis is a self-limiting condition in which the urethral opening becomes reddened and inflamed after the procedure. Absent voiding and increased irritability 4 hours postprocedure are not reportable concerns. Based on the method of infant feeding, the infant would void within 6 to 8 hours after the procedure. Irritability is common after the procedure. p. 478, 482 Report content error Which risk factor is associated with elevated bilirubin in the newborn? Select all that apply. One, some, or all responses may be correct. Rationale Hypoglycemia, delayed feeding, an infant who is born late preterm, and an infant with an incompatible Rh factor are all associated with elevated bilirubin levels. Caput succedaneum is an accumulation of fluid that Hypoglycemia Delayed feeding Late preterm infant Caput succedaneum Incompatible Rhesus (Rh) factorcauses swelling of the scalp, crosses the suture lines; it does not increase the risk of elevated bilirubin. p. 457 Report content error Which physiologic change occurs after the infant takes the first breath? Rationale As the newborn takes the first breath, the rise in the blood's oxygen level causes the ductus arteriosus to constrict. Systemic pressure increases when the cord is clamped. The changes that occur after the first breath result in a decrease in pulmonary vascular resistance, thus decreasing the pulmonary pressure. The pressure on the left side of the heart increases, and the right side decreases. p. 432 Decreased systemic pressure Increased pulmonary pressure Constriction of the ductus arteriosus Uniform pressure on the right and left side of the heartReport content error Place in the correct order the instructions a breastfeeding patient would use to care for an occluded lactiferous duct. 1. 2. 3. 4. Rationale The nurse will instruct a patient with an occluded lactiferous duct to massage the area, apply a warm compress, continue to breastfeed using varied breastfeeding positions, and monitor for mastitis. Test-Taking Tip: In this question type, you are asked to prioritize (put in order) the options presented. For example, you might be asked the steps of performing an action or skill such as those involved in medication administration. p. 499 Massage the area. Apply a warm compress. Alter breastfeeding positions. Monitor for mastitis.Report content error Which initial prescription will the nurse anticipate administering to a newborn scheduled for circumcision? Select all that apply. One, some, or all responses may be correct. Rationale The initial prescriptions administered to a newborn scheduled for a circumcision include acetaminophen and a topical anesthetic. Acetaminophen is given before the procedure and throughout the first postoperative day for pain. The nurse will also administer a topical anesthetic, specifically made from a eutectic mixture of local anesthetic (EMLA), generally an hour before the circumcision. An antibiotic is not routinely administered for a circumcision. Immediately before and during the procedure, oral sucrose can be used to help soothe the infant. The healthcare practitioner administers a penile block before the procedure. p. 478 Antibiotic Oral sucrose Penile block Acetaminophen Topical anesthetic4 topics covered Chapter 21, The Normal Newborn: Adaptati… McKinney: Maternal-Child Nursing, Sixth Edition You Chapter 23, Newborn Feeding McKinney: Maternal-Child Nursing, Sixth Edition Novice You Chapter 22, The Normal Newborn: Nursing… McKinney: Maternal-Child Nursing, Sixth Edition Novice You Quiz me on this topic Quiz me on this topic Quiz me on this topic Novice Intermediate Proficient Questions answered 10 Novice Intermediate Proficient Questions answered 14 Novice Intermediate Proficient Questions answered 14Chapter 20, Postpartum Adaptations McKinney: Maternal-Child Nursing, Sixth Edition Novice You Quiz me on this topic Novice Intermediate Proficient Questions answered 19