QUESTIONS AND SOLUTIONS
◉A nurse is caring for a client who experienced a vaginal birth 12 hr
ago. The nurse recognizes the client is in the dependent, taking in
phase of maternal postpartum adjustment. Which of the following
findings should the nurse expect during this phase?
A. Expressions of excitement
B. Lack of appetite
C. Focus on the family unit and its members
D. Eagerness to learn newborn care skills. Answer: A. Expressions of
excitement
Expressing excitement and being talkative are characteristic of this
phase.
◉A nurse is caring for a client who is 1 day postpartum and is taking
a sitz bath. To determine the client's tolerance of the procedure,
which of the following assessments should the nurse perform?
A. Bladder distention
B. Pulse rate
C. Respiratory rate
D. Color of lochia. Answer: B. Pulse rate
, A sitz bath causes vasodilation; therefore, the nurse should monitor
the client's pulse rate. Orthostatic hypotension can occur upon
standing causing the client to feel faint.
◉A nurse is preparing to administer 1 mg vitamin K to a newborn.
The medication is available in 1 mg/0.5 mL. How much should the
nurse administer?. Answer: 0.5 mL
◉A nurse is preparing to assess a newborn who is postmature.
Which of the following findings should the nurse expect? (SATA)
A. Cracked, peeling skin
B. Positive Moro reflex
C. Short, soft fingernails
D. Abundant lanugo
E. Vernix in the folds and creases. Answer: A B
◉A nurse is teaching an assistive personnel to measure a newborn's
respiratory rate. Which of the following statements indicates an
understanding of why the respiratory rate should be counted for a
complete minute?
A. "Newborns are abdominal breathers."
B. "Newborns do not expand their lungs fully with each respiration."
C. "Activity will increase the respiratory rate."