. What should be included in a teaching plan regarding breast engorgement?

a.
It typically occurs on the first postpartum day
b.
It is usually first observed in the axillary region
c.
It occurs only in women who are not breastfeeding
d.
It occurs near the nipple on the third postpartum day
ANS: B

Filling of the breast with milk (engorgement) usually begins in the axillary region on the
third postpartum day when the milk comes in. It occurs regardless of whether the
mother is breastfeeding or bottle-feeding.
5. When is breast engorgement most likely to occur?

a.
When the infant's mouth surrounds the areola when feeding
b.
When the breast tissue becomes congested
c.
When the breast is emptied completely at each feeding
d.
When the infant's mouth grasps the nipple firmly
ANS: B
Engorgement is the result of venous and lymphatic stasis (congestion). Emptying the
breast at each feeding, the infant grasping the nipple firmly, and the infant's mouth
surrounding the areola when feeding are all measures that will aid in decreasing
engorgement.
6. Which statement would be a correct description of colostrum?

a.
Slightly yellow and low in protein
b.
Slightly yellow and provides antibodies
c.
Creamy and high in fat and protein
d.
Colorless and high in fat and carbohydrates
ANS: B
Colostrum is slightly yellow in color and is rich in antibodies.

The new mother has decided not to breastfeed the baby. How should the nurse
correctly instruct the mother to suppress her milk supply?
a.
Pump the breasts to remove milk
b.
Apply warm, moist compresses
c.
Restrict oral fluids
d.
Apply a firm bra and ice packs
ANS: D

If a patient is not breastfeeding, compress the breasts with a firm bra and wrapped ice
packs to suppress the milk supply. Pumping the breasts and applying warm, moist
compresses are instructions for the breastfeeding mother to deal with the painful
symptoms of engorgement.
8. During the immediate postpartum period, the mother has a temperature of 100.2° F,
pulse 52, respirations 18, BP 138/84. What should the nurse do?
a.
Report the temperature as abnormal
b.
Continue to monitor every 15 minutes
c.
Report the pulse as abnormal
d.
Nothing as the vital signs are normal
ANS: D

The vital signs are normal for a new postpartum patient.

The new mother has decided not to breastfeed the baby. How should the nurse
correctly instruct the mother to suppress her milk supply?
a.
Pump the breasts to remove milk
b.
Apply warm, moist compresses
c.
Restrict oral fluids
d.
Apply a firm bra and ice packs
ANS: D

If a patient is not breastfeeding, compress the breasts with a firm bra and wrapped ice
packs to suppress the milk supply. Pumping the breasts and applying warm, moist
compresses are instructions for the breastfeeding mother to deal with the painful
symptoms of engorgement.
8. During the immediate postpartum period, the mother has a temperature of 100.2° F,
pulse 52, respirations 18, BP 138/84. What should the nurse do?
a.
Report the temperature as abnormal
b.
Continue to monitor every 15 minutes
c.
Report the pulse as abnormal
d.
Nothing as the vital signs are normal
ANS: D

The vital signs are normal for a new postpartum patient.

The postpartum mother with a third degree laceration tells the nurse she is afraid to have a
bowel movement because of her painful episiotomy. What should the nurse do?

a.
Offer a suppository or enema
b.
Encourage ambulation
c.
Offer stool softeners as prescribed
d.
Offer pain medication before defecating The postpartum mother with a third degree laceration
tells the nurse she is afraid to have a bowel movement because of her painful episiotomy. What
should the nurse do?

a.
Offer a suppository or enema
b.
Encourage ambulation
c.
Offer stool softeners as prescribed
d.
Offer pain medication before defecating

Which finding should the nurse suspect as abnormal in the newborn during the initial
assessment?

a.
Eyes crossed at times
b.
Persistent high-pitched cry
c.
Arms and legs flexed
d.
Slight bluish tinge of the extremities
ANS: B

A high-pitched cry may indicate neurologic problems. Occasional crossing of the eyes,
flexing of the arms and legs, and a bluish tinge of the extremities are all considered
normal assessment findings in the newborn.
Which finding should the nurse suspect as abnormal in the newborn during the initial
assessment?

a.
Eyes crossed at times
b.
Persistent high-pitched cry
c.
Arms and legs flexed
d.
Slight bluish tinge of the extremities
ANS: B

A high-pitched cry may indicate neurologic problems. Occasional crossing of the eyes,
flexing of the arms and legs, and a bluish tinge of the extremities are all considered
normal assessment findings in the newborn.

The nurse is giving a bath demonstration for a group of new mothers. What should be included
in the demonstration?

a.
Apply baby powder generously to keep baby dry.
b.
Cleanse perineum from front to back.
c.
Use scented soap to make baby smell good.
d.
Partially submerge head in water when shampooing.

A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia
(PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She is now
complaining of nausea and bloating, and states that because she had nothing to eat, she is too
weak to breastfeed her infant. Which nursing diagnosis has the highest priority?
A. Altered nutrition, less than body requirements for lactation
B. Alteration in comfort related to nausea and abdominal distention
C. Impaired bowel motility related to pain medication and immobility
D.NFatigue related to cesarean delivery and physical care demands of infantA client who
delivered by cesarean section 24 hours ago is using a patient-controlled analgesia (PCA) pump
for pain control. Her oral intake has been ice chips only since surgery. She is now complaining
of nausea and bloating, and states that because she had nothing to eat, she is too weak to
breastfeed her infant. Which nursing diagnosis has the highest priority?
A. Altered nutrition, less than body requirements for lactation
B. Alteration in comfort related to nausea and abdominal distention
C. Impaired bowel motility related to pain medication and immobility
D.NFatigue related to cesarean delivery and physical care demands of infant

The nurse is teaching care of the newborn to a childbirth preparation class and describes the
need for administering antibiotic ointment into the eyes of the newborn. An expectant father
asks, "What type of disease causes infections in babies that can be prevented by using this
ointment?" Which response by the nurse is accurate?
A.NHerpes
B. Trichomonas
C. Gonorrhea
D. Syphilis

A new mother is having trouble breastfeeding her newborn. The child is making frantic
rooting motions and will not grasp the nipple. Which intervention should the nurse
implement?
A. Encourage frequent use of a pacifier so that the infant becomes accustomed to
sucking.
B. Hold the infant's head firmly against the breast until he latches onto the nipple.
C. Encourage the mother to stop feeding for a few minutes and comfort the infant.
D. Provide formula for the infant until he becomes calm, and then offer the breast again.
C. Rationale: The infant is becoming frustrated and so is the mother; both need a time
out. The mother should be encouraged to comfort the infant and to relax herself (C).
After such a time out, breastfeeding is often more successful. (A and D) would cause
nipple confusion. (B) would only cause the infant to be more resistant, resulting in the
mother and infant to become more frustrated.

Which statement made by the client indicates that the mother understands the
limitations of breastfeeding her newborn?
A. "Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my
period."
B. "Breastfeeding my baby immediately after drinking alcohol is safer than waiting for
the alcohol to clear my breast milk. "
C. "I can start smoking cigarettes while breastfeeding because it will not affect my
breast milk. "
D. "When I take a warm shower after I breastfeed, it relieves the pain from being
engorged between breastfeedings. "
A. Rationale: Continuous breastfeeding on a 3- to 4-hour schedule during the day will
cause a release of prolactin, which will suppress ovulation and menses, but is not
completely effective as a birth control method (A). (B) is incorrect because alcohol can
immediately enter the breast milk. Nicotine is transferred to the infant in breast milk (C).
Taking a warm shower will stimulate the production of milk, which will be more painful
after breastfeedings (D).
The nurse encourages the mother of a healthy newborn to put the newborn to the
breast immediately after birth for which reason?

A) To aid in maturing the newborn's sucking

reflex
B) To encourage the development of maternal antibodies
C) To facilitate maternal-infant bonding
D) To enhance the clearing of the newborn's respiratory passages
C
Breast-feeding can be initiated immediately after birth. This immediate mother-newborn
contact takes advantage of the newborn's natural alertness and fosters bonding. This
contact also reduces maternal bleeding and stabilizes the newborn's temperature, blood
glucose level, and respiratory rate. It is not associated with maturing the sucking reflex,
encouraging the development of maternal antibodies, or aiding in clearing of the
newborn's respiratory passages.