- A nurse is assessing a primigravida at 39 weeks' gestation in early labor. The fetal heart rate baseline is 140 bpm with moderate variability and accelerations present. How should the nurse interpret this tracing?
- Late decelerations requiring intervention
- Category I, reassuring
- Category III, abnormal
- Category II, indeterminate
Correct answer: Category I, reassuring
A baseline of 110-160 bpm with moderate variability, accelerations, and no late or variable decelerations is a Category I tracing, which is reassuring and predictive of normal fetal acid-base status.
- During the postpartum assessment of a woman 2 hours after vaginal delivery, the nurse palpates the fundus and finds it boggy and displaced to the right above the umbilicus. What is the priority nursing action?
- Administer methylergonovine immediately
- Document the finding and reassess in 4 hours
- Apply ice to the perineum
- Massage the fundus and have the woman void
Correct answer: Massage the fundus and have the woman void
A boggy fundus displaced to the right suggests a full bladder preventing uterine contraction. Massaging the fundus and having the woman empty her bladder allow the uterus to contract and reduce hemorrhage risk.
- A newborn is 1 minute old with a heart rate of 90 bpm, slow irregular respirations, some flexion of extremities, a grimace to suction, and a body that is pink with blue extremities. What is the Apgar score?
Correct answer: 5
Heart rate <100 = 1, slow/irregular respirations = 1, some flexion = 1, grimace = 1, acrocyanosis = 1, totaling 5.
- A breastfeeding mother reports sore, cracked nipples on day 3 postpartum. After observing a feeding, the nurse notes the infant's lips are tucked inward and only the nipple tip is in the mouth. What is the most appropriate intervention?
- Apply an antifungal cream to the nipples
- Recommend stopping breastfeeding for 48 hours
- Switch the infant to formula feeding
- Reposition the infant to achieve a deeper latch with flanged lips
Correct answer: Reposition the infant to achieve a deeper latch with flanged lips
Shallow latch with inverted lips is a leading cause of nipple trauma. Correcting positioning so the infant takes in more areola with lips flanged outward relieves pain and promotes effective milk transfer.
- A laboring woman at 5 cm dilation suddenly reports a gush of fluid. The nurse observes greenish-tinged amniotic fluid and a fetal heart rate deceleration. What does the green color most likely indicate?
- Maternal infection
- Meconium-stained amniotic fluid
- Normal amniotic fluid
- Bloody show
Correct answer: Meconium-stained amniotic fluid
Green-tinged amniotic fluid indicates meconium passage in utero, which can signal fetal stress and increases the risk of meconium aspiration, requiring readiness for neonatal resuscitation.
- A nurse is teaching new parents about safe sleep to reduce SIDS risk. Which statement by a parent indicates correct understanding?
- I will place a pillow under the baby's head
- I will use soft bumper pads in the crib
- I will put my baby to sleep on the back on a firm mattress
- I will place my baby on the side to sleep
Correct answer: I will put my baby to sleep on the back on a firm mattress
The safest sleep practice is supine (back) positioning on a firm, flat surface free of soft bedding, pillows, and bumpers, which reduces the risk of SIDS and suffocation.
- A woman with gestational diabetes delivers a 4,300 gram infant. Two hours after birth the infant is jittery, has a weak cry, and a heel-stick glucose of 35 mg/dL. What is the priority intervention?
- Place the infant under a radiant warmer only
- Feed the infant or provide glucose per protocol and recheck
- Initiate phototherapy
- Administer oxygen by mask
Correct answer: Feed the infant or provide glucose per protocol and recheck
Infants of diabetic mothers are at risk for hypoglycemia due to hyperinsulinemia. A glucose of 35 mg/dL with symptoms requires feeding or dextrose per protocol followed by a recheck.
- Which assessment finding in a postpartum woman on day 1 is most concerning and requires immediate provider notification?
- Lochia rubra with a few small clots
- Saturating a perineal pad within 15 minutes
- Afterpains during breastfeeding
- Diaphoresis at night
Correct answer: Saturating a perineal pad within 15 minutes
Saturating a pad within 15 minutes indicates excessive bleeding (more than 1 pad per hour) and possible postpartum hemorrhage, requiring immediate evaluation. The other findings are expected.
- A nurse notes a newborn has a yellowish tint to the skin and sclera at 18 hours of life. What does jaundice appearing within the first 24 hours most likely indicate?
- Physiologic jaundice
- Pathologic jaundice requiring evaluation
- Breast milk jaundice
- Normal newborn variation
Correct answer: Pathologic jaundice requiring evaluation
Jaundice appearing before 24 hours of age is considered pathologic and warrants prompt bilirubin evaluation, often associated with hemolytic processes such as ABO or Rh incompatibility.
- A pregnant woman at 32 weeks presents with a blood pressure of 158/102, 3+ proteinuria, and complaints of a severe headache and visual changes. These findings are consistent with which condition?
- HELLP syndrome only
- Chronic hypertension
- Preeclampsia with severe features
- Gestational hypertension
Correct answer: Preeclampsia with severe features
Blood pressure of 160/110 or higher (or near it) with proteinuria plus cerebral or visual symptoms indicates preeclampsia with severe features, requiring close monitoring and possible magnesium sulfate.
- A woman receiving magnesium sulfate for severe preeclampsia has a respiratory rate of 10, absent deep tendon reflexes, and decreased urine output. What is the priority action?
- Increase the magnesium sulfate infusion
- Stop the infusion and prepare to administer calcium gluconate
- Administer a fluid bolus
- Reposition the patient
Correct answer: Stop the infusion and prepare to administer calcium gluconate
Respiratory depression and absent reflexes signal magnesium toxicity. The infusion should be stopped immediately and calcium gluconate, the antidote, prepared for administration.
- When teaching cord care to new parents, which instruction is most appropriate?
- Apply alcohol to the cord with every diaper change
- Cover the cord with an occlusive dressing
- Keep the cord dry and fold the diaper below it
- Pull gently on the cord daily to speed separation
Correct answer: Keep the cord dry and fold the diaper below it
Current evidence supports dry cord care, keeping the area clean and dry and folding the diaper below the stump to promote natural drying and separation while reducing infection risk.
- A multiparous woman delivers and the placenta is delivered intact. Within 10 minutes she has heavy bright red bleeding despite a firm fundus. What is the most likely cause?
- Coagulopathy
- Uterine atony
- Cervical or vaginal laceration
- Retained placental fragments
Correct answer: Cervical or vaginal laceration
Bright red bleeding with a firm, well-contracted fundus suggests a genital tract laceration rather than atony, which would present with a soft, boggy uterus.
- A newborn fails the initial hearing screen prior to discharge. What is the most appropriate nursing response to the parents?
- Explain that a follow-up rescreen or audiology referral is needed
- Reassure them that newborns cannot hear yet
- Recommend immediate cochlear implant evaluation
- Tell them the baby is likely deaf
Correct answer: Explain that a follow-up rescreen or audiology referral is needed
An initial failed screen is common due to fluid or debris and does not confirm hearing loss. The appropriate step is reassurance plus arranging timely follow-up rescreening or audiology referral.
- A postpartum woman 4 days after cesarean birth reports a warm, reddened, tender area on her left calf with swelling. What should the nurse suspect?
- Muscle strain
- Cellulitis of the incision
- Normal postpartum swelling
- Deep vein thrombosis
Correct answer: Deep vein thrombosis
Unilateral calf warmth, redness, tenderness, and swelling in the postpartum period are classic signs of deep vein thrombosis, a hypercoagulable-state complication requiring evaluation.
- A nurse is assessing a 36-hour-old newborn. Which finding requires further evaluation rather than reassurance?
- Acrocyanosis
- Pseudomenstruation in a female infant
- Milia on the nose
- Respiratory rate of 75 with grunting
Correct answer: Respiratory rate of 75 with grunting
A respiratory rate over 60 with grunting indicates respiratory distress and requires evaluation. Acrocyanosis, milia, and pseudomenstruation are normal newborn findings.
- A laboring woman's fetal heart tracing shows recurrent late decelerations with minimal variability. What is the priority nursing intervention?
- Continue routine monitoring
- Encourage maternal pushing
- Reposition to left lateral, give oxygen, and increase IV fluids
- Apply external pressure to the fundus
Correct answer: Reposition to left lateral, give oxygen, and increase IV fluids
Late decelerations indicate uteroplacental insufficiency. Intrauterine resuscitation measures are lateral repositioning, an IV fluid bolus, and stopping oxytocin if infusing; supplemental oxygen is no longer recommended as a routine measure (current ACOG guidance) and is reserved for documented maternal hypoxemia.
- Which finding indicates effective breastfeeding in a 4-day-old newborn?
- Weight loss of 12 percent from birth weight
- Feeding every 6 hours
- Two wet diapers in 24 hours
- Six to eight wet diapers and several stools in 24 hours
Correct answer: Six to eight wet diapers and several stools in 24 hours
By day 4, an adequately fed breastfeeding newborn typically produces six or more wet diapers and several stools daily, reflecting adequate intake and hydration.
- A woman at 30 weeks' gestation reports painless, bright red vaginal bleeding. The nurse should suspect which condition and avoid which action?
- Abruptio placentae; avoid IV fluids
- Normal bloody show; avoid notifying the provider
- Preterm labor; avoid fetal monitoring
- Placenta previa; avoid vaginal examination
Correct answer: Placenta previa; avoid vaginal examination
Painless bright red bleeding in the third trimester suggests placenta previa. Digital vaginal examination is contraindicated because it may provoke severe hemorrhage.
- A newborn of a mother who used opioids during pregnancy shows high-pitched crying, tremors, poor feeding, and a temperature of 37.8 C. These findings are consistent with what condition?
- Hypoglycemia
- Neonatal sepsis
- Hypothermia
- Neonatal abstinence syndrome
Correct answer: Neonatal abstinence syndrome
Neonatal abstinence syndrome presents with CNS hyperirritability (high-pitched cry, tremors), feeding difficulties, and autonomic signs in infants exposed to opioids in utero.
- A postpartum patient confides that she feels overwhelmed, cannot sleep even when the baby sleeps, has no interest in the baby, and has had thoughts of harming herself. What is the priority nursing action?
- Reassure her these feelings are normal baby blues
- Encourage more rest and reassess in a week
- Recommend she stop breastfeeding
- Ensure immediate safety and arrange urgent mental health evaluation
Correct answer: Ensure immediate safety and arrange urgent mental health evaluation
Thoughts of self-harm with loss of interest in the infant indicate possible postpartum depression with safety risk, requiring immediate safety assessment and urgent psychiatric referral.
- Which newborn finding is an expected variation of normal at 24 hours of age?
- Single transverse palmar crease with hypotonia
- Bilious vomiting
- Bulging fontanelle
- Mongolian spots over the sacrum
Correct answer: Mongolian spots over the sacrum
Mongolian spots (congenital dermal melanocytosis) are benign bluish pigmented areas common over the sacrum, especially in darker-skinned infants, and require no intervention.
- A nurse is caring for a woman in active labor receiving an oxytocin infusion. Contractions are now occurring every 90 seconds, lasting 100 seconds, with a fetal heart rate showing late decelerations. What is the priority action?
- Discontinue the oxytocin infusion
- Apply a fetal scalp electrode
- Increase the oxytocin rate
- Encourage Valsalva pushing
Correct answer: Discontinue the oxytocin infusion
Tachysystole with abnormal fetal heart rate indicates uterine overstimulation. Oxytocin should be stopped immediately to allow uterine relaxation and improved placental perfusion.
- A nurse reviews lab results for a postpartum woman with HELLP syndrome. Which set of findings is consistent with this diagnosis?
- High platelets, low liver enzymes, no hemolysis
- Hemolysis, elevated liver enzymes, low platelets
- Normal platelets with elevated glucose
- Leukocytosis with low liver enzymes
Correct answer: Hemolysis, elevated liver enzymes, low platelets
HELLP syndrome is defined by Hemolysis, Elevated Liver enzymes, and Low Platelets, a severe variant of preeclampsia associated with significant maternal morbidity.
- Which intervention best prevents heat loss by evaporation in a newborn immediately after birth?
- Drying the infant thoroughly and removing wet linens
- Positioning near an exterior window
- Placing the infant on a cold scale
- Placing the infant on a metal surface
Correct answer: Drying the infant thoroughly and removing wet linens
Evaporative heat loss occurs as moisture on the skin evaporates. Promptly drying the infant and removing wet linens minimizes this loss and supports thermoregulation.
- A primipara asks when she can expect her milk to come in. The most accurate response is:
- Only after the first menstrual period
- Within the first 6 hours after birth
- After 2 weeks postpartum
- Around 2 to 5 days postpartum
Correct answer: Around 2 to 5 days postpartum
Copious milk production (lactogenesis II) typically begins around 2 to 5 days postpartum as colostrum transitions to mature milk, prompted by the drop in progesterone after placental delivery.
- A nurse assesses a newborn and notes a positive Ortolani maneuver with a palpable clunk. What does this finding suggest?
- Normal hip development
- Developmental dysplasia of the hip
- Clubfoot
- Spinal cord defect
Correct answer: Developmental dysplasia of the hip
A positive Ortolani sign (a clunk as the dislocated femoral head reduces into the acetabulum) indicates developmental dysplasia of the hip and requires orthopedic referral.
- A laboring woman receives an epidural and shortly after develops a blood pressure of 88/50 with a fetal heart rate deceleration. What is the priority nursing intervention?
- Reposition to lateral, give IV fluid bolus, and notify provider
- Encourage immediate pushing
- Withhold all IV fluids
- Place in high Fowler's position
Correct answer: Reposition to lateral, give IV fluid bolus, and notify provider
Maternal hypotension is a common epidural complication causing reduced placental perfusion. Lateral repositioning, IV fluid bolus, and provider notification (with vasopressors as ordered) restore perfusion.
- Which finding in a 6-hour-old newborn most strongly suggests neonatal sepsis?
- Sneezing while in an open crib
- A single episode of regurgitation
- Acrocyanosis after a bath
- Temperature instability and lethargy with poor feeding
Correct answer: Temperature instability and lethargy with poor feeding
Temperature instability, lethargy, and poor feeding are nonspecific but important early signs of neonatal sepsis, warranting a sepsis workup given the infant's immature immune system.
- A nurse is teaching a postpartum woman about lochia progression. Which statement indicates a need for further teaching?
- Lochia serosa is pinkish-brown
- Lochia rubra is red and lasts about 3 days
- A return to bright red bleeding after lochia serosa is normal
- Lochia alba is yellowish-white
Correct answer: A return to bright red bleeding after lochia serosa is normal
Lochia should progress from rubra to serosa to alba. A return to bright red bleeding may indicate retained placental fragments or subinvolution and should be reported, so this statement requires correction.
- A nurse caring for a preterm infant at 32 weeks observes nasal flaring, grunting, and intercostal retractions. These signs are most consistent with which condition?
- Choanal atresia
- Pneumothorax
- Respiratory distress syndrome from surfactant deficiency
- Transient tachypnea of the newborn
Correct answer: Respiratory distress syndrome from surfactant deficiency
Preterm infants are at high risk for respiratory distress syndrome due to surfactant deficiency, which causes alveolar collapse and signs of respiratory distress such as grunting and retractions.
- A woman with type 1 diabetes is pregnant. Tight glycemic control is most important in the first trimester to prevent which complication?
- Congenital anomalies
- Neonatal hypoglycemia
- Polyhydramnios
- Macrosomia
Correct answer: Congenital anomalies
Hyperglycemia during organogenesis in the first trimester increases the risk of congenital anomalies, particularly cardiac and neural tube defects, so early glycemic control is critical.
- Which technique should the nurse use to assess for jaundice in a newborn with darker skin pigmentation?
- Assume jaundice is absent if the infant is feeding
- Inspect only the soles of the feet
- Rely solely on visual inspection of the trunk
- Blanch the skin over a bony prominence and observe the sclera and mucous membranes
Correct answer: Blanch the skin over a bony prominence and observe the sclera and mucous membranes
In darker-skinned infants, jaundice is best detected by blanching the skin over a bony area and examining the sclera and oral mucous membranes; transcutaneous or serum bilirubin confirms the level.
- A postpartum woman who is Rh-negative delivers an Rh-positive infant and has a negative indirect Coombs test. What is the appropriate nursing action?
- Administer Rho(D) immune globulin within 72 hours
- No intervention is needed
- Begin an exchange transfusion
- Administer Rho(D) immune globulin to the newborn
Correct answer: Administer Rho(D) immune globulin within 72 hours
An Rh-negative, unsensitized mother of an Rh-positive infant should receive Rho(D) immune globulin within 72 hours of delivery to prevent maternal isoimmunization in future pregnancies.
- A nurse observes a newborn during feeding and notes choking, coughing, and cyanosis with attempts to feed, plus excessive oral secretions. What condition should be suspected?
- Gastroesophageal reflux
- Tracheoesophageal fistula or esophageal atresia
- Cleft lip
- Pyloric stenosis
Correct answer: Tracheoesophageal fistula or esophageal atresia
Choking, coughing, cyanosis with feeds, and excessive secretions suggest tracheoesophageal fistula or esophageal atresia, which require immediate evaluation and withholding of oral feeds.
- A nurse is providing discharge teaching on newborn temperature taking. Which method does the nurse recommend for routine home use?
- Axillary temperature
- Tympanic temperature in the first week
- Oral temperature
- Rectal temperature with every diaper change
Correct answer: Axillary temperature
Axillary temperature is the recommended noninvasive method for routine newborn monitoring at home, avoiding the risks of rectal perforation and the inaccuracy of tympanic readings in newborns.
- A woman in labor at term has a prolapsed umbilical cord visible at the introitus. What is the priority nursing action?
- Clamp the cord and cut it
- Attempt to replace the cord into the vagina
- Elevate the presenting part off the cord and call for immediate help
- Place the woman in a sitting position
Correct answer: Elevate the presenting part off the cord and call for immediate help
Cord prolapse is an obstetric emergency. The nurse uses a gloved hand to lift the presenting part off the cord, positions the woman to relieve pressure, and summons help for emergency delivery.
- A postpartum woman 3 days after delivery has a temperature of 38.5 C, uterine tenderness, and foul-smelling lochia. What complication is most likely?
- Mastitis
- Urinary tract infection
- Wound dehiscence
- Endometritis
Correct answer: Endometritis
Fever, uterine tenderness, and foul-smelling lochia after delivery are hallmark signs of endometritis, a uterine infection requiring antibiotic therapy.
- Which newborn requires the most immediate evaluation for a cardiac defect?
- A newborn with central cyanosis unresponsive to oxygen
- A newborn with acrocyanosis that resolves with warming
- A newborn with a transient murmur that disappears by 48 hours
- A newborn with pink mucous membranes and good perfusion
Correct answer: A newborn with central cyanosis unresponsive to oxygen
Central cyanosis that does not improve with supplemental oxygen suggests a cyanotic congenital heart defect with right-to-left shunting and requires urgent cardiology evaluation.
- A nurse is reinforcing teaching about pumping and storing breast milk. Which statement by the mother indicates correct understanding?
- Thawed breast milk can be refrozen
- Freshly pumped milk can stay at room temperature for 12 hours
- Refrigerated breast milk can be stored for about 4 days
- Breast milk should be heated in the microwave
Correct answer: Refrigerated breast milk can be stored for about 4 days
Freshly expressed breast milk can be stored safely in the refrigerator for about 4 days. Milk should not be refrozen after thawing nor microwaved due to uneven heating and nutrient loss.
- A nurse is assessing a newborn's reflexes. When the nurse strokes the side of the cheek, the infant turns the head toward the stimulus and opens the mouth. This reflex is called:
- Tonic neck reflex
- Rooting reflex
- Babinski reflex
- Moro reflex
Correct answer: Rooting reflex
The rooting reflex causes the newborn to turn toward a cheek stimulus and open the mouth, an adaptive reflex that facilitates locating the nipple for feeding.
- During the fourth stage of labor, which assessment finding indicates the woman is at greatest risk for hemorrhage?
- Moderate lochia rubra
- Blood pressure of 118/72
- An overdistended bladder displacing the uterus
- A firm fundus at the umbilicus
Correct answer: An overdistended bladder displacing the uterus
A distended bladder prevents the uterus from contracting effectively, increasing the risk of uterine atony and postpartum hemorrhage; bladder emptying is essential.
- A nurse provides care for a newborn with a positive direct Coombs test and rising bilirubin from ABO incompatibility. Which intervention is most likely indicated?
- Phototherapy
- Withholding all feedings
- Immediate surgery
- Strict fluid restriction
Correct answer: Phototherapy
ABO incompatibility causes hemolysis and rising bilirubin. Phototherapy converts bilirubin to a water-soluble form for excretion and is the standard first-line treatment for hyperbilirubinemia.
- A nurse is teaching a postpartum woman about danger signs to report after discharge. Which sign requires immediate reporting?
- Mild afterpains for the first few days
- Breast fullness on day 3
- A temperature of 38.5 C or higher
- Lochia changing from red to brown
Correct answer: A temperature of 38.5 C or higher
A temperature of 38 C (100.4 F) or higher after the first 24 hours postpartum may indicate infection and should be reported promptly; 38.5 C is clearly above that threshold. The other findings are expected postpartum changes.
- A newborn at 2 days old has not passed meconium and has a distended abdomen with bilious vomiting. What does the nurse suspect?
- Physiologic jaundice
- Mild reflux
- Intestinal obstruction such as Hirschsprung disease or atresia
- Normal newborn variation
Correct answer: Intestinal obstruction such as Hirschsprung disease or atresia
Failure to pass meconium within 48 hours with abdominal distension and bilious vomiting suggests intestinal obstruction (e.g., Hirschsprung disease or atresia) requiring urgent evaluation.
- A laboring woman at 6 cm reports the urge to push. The fetal heart rate is reassuring and a vaginal exam reveals she is now 10 cm and fully effaced. What is the appropriate nursing action?
- Apply fundal pressure
- Support pushing efforts as she has reached complete dilation
- Tell her not to push under any circumstances
- Administer a tocolytic
Correct answer: Support pushing efforts as she has reached complete dilation
At complete (10 cm) dilation and effacement with a reassuring fetal heart rate, the woman is in the second stage of labor and may begin pushing with appropriate support.
- Which intervention is most important when caring for a newborn under phototherapy?
- Withhold feedings during treatment
- Cover the eyes and monitor temperature and hydration
- Dress the infant warmly to prevent chilling
- Keep the infant fully clothed
Correct answer: Cover the eyes and monitor temperature and hydration
During phototherapy, eye shields protect the retina, and the nurse monitors temperature and hydration because of insensible fluid loss and the risk of overheating or hypothermia.
- A nurse notes that a postpartum woman who delivered 12 hours ago has not voided and reports lower abdominal pressure. Bladder distension is palpable. What is the priority concern?
- Normal bladder tone
- Dehydration
- Urinary retention increasing hemorrhage and infection risk
- Normal postpartum diuresis
Correct answer: Urinary retention increasing hemorrhage and infection risk
Postpartum urinary retention from decreased bladder tone and perineal edema can lead to uterine displacement, atony, hemorrhage, and infection, so prompt voiding or catheterization is needed.
- A nurse is performing newborn resuscitation. After drying, warming, positioning, and clearing the airway, the heart rate is 70 bpm. What is the next step?
- Begin chest compressions
- Administer epinephrine
- Initiate positive pressure ventilation
- Continue routine observation
Correct answer: Initiate positive pressure ventilation
If the heart rate is below 100 after the initial steps, positive pressure ventilation is the priority intervention, as effective ventilation is the most important component of neonatal resuscitation.
- A woman expresses cultural beliefs about postpartum practices that differ from standard unit routines but pose no safety risk. What is the most appropriate nursing response?
- Tell her the practices are unsafe without assessment
- Insist she follow hospital routines exactly
- Document noncompliance in the record
- Accommodate her culturally specific practices within safe limits
Correct answer: Accommodate her culturally specific practices within safe limits
Culturally competent care respects and incorporates patient beliefs and practices when they do not compromise safety, supporting trust and patient-centered care.
- A newborn weighing 2,200 grams at 37 weeks is classified as which of the following?
- Post-term
- Small for gestational age
- Appropriate for gestational age
- Large for gestational age
Correct answer: Small for gestational age
A weight below the 10th percentile for gestational age classifies the infant as small for gestational age, which raises the risk of hypoglycemia, hypothermia, and polycythemia.
- A breastfeeding mother on day 5 reports a hard, red, tender area in one breast with a fever and flu-like symptoms. What condition is most likely?
- Engorgement
- Plugged duct only
- Normal let-down
- Mastitis
Correct answer: Mastitis
A localized, red, tender area with fever and systemic flu-like symptoms indicates mastitis, an inflammation often with infection, treated with continued breastfeeding, rest, and antibiotics as indicated.
- Which finding in the immediate newborn period is the most reliable early indicator of adequate cardiopulmonary transition?
- Presence of acrocyanosis
- Passage of meconium
- Presence of vernix
- Sustained heart rate above 100 bpm with spontaneous respirations
Correct answer: Sustained heart rate above 100 bpm with spontaneous respirations
A sustained heart rate above 100 bpm with regular spontaneous respirations indicates successful transition to extrauterine life and adequate oxygenation.
- A nurse is teaching about formula preparation. Which statement requires correction?
- Adding extra water makes the formula last longer and is fine
- I will discard formula left out more than 2 hours
- I will wash my hands before preparing formula
- I will follow the mixing instructions exactly
Correct answer: Adding extra water makes the formula last longer and is fine
Diluting formula with extra water reduces caloric and nutrient intake and can cause water intoxication and hyponatremia, so it requires correction.
- A postpartum woman who had a precipitous delivery is at increased risk for which complication?
- Cervical incompetence
- Failure to progress
- Uterine atony and lacerations
- Prolonged labor
Correct answer: Uterine atony and lacerations
Precipitous (very rapid) delivery increases the risk of uterine atony from rapid stretching and genital tract lacerations from rapid descent, both raising hemorrhage risk.
- A newborn at 1 hour of age has a respiratory rate of 80, mild grunting, and was born by cesarean at 39 weeks. Symptoms gradually improve over hours. What is the most likely diagnosis?
- Congenital pneumonia
- Meconium aspiration syndrome
- Respiratory distress syndrome
- Transient tachypnea of the newborn
Correct answer: Transient tachypnea of the newborn
Transient tachypnea of the newborn results from delayed clearance of fetal lung fluid, is more common after cesarean birth, and typically resolves within 24 to 72 hours.
- A nurse is caring for a woman with chorioamnionitis in labor. Which newborn assessment is the highest priority after birth?
- Hearing screen
- Eye prophylaxis
- Weight measurement
- Signs of neonatal sepsis
Correct answer: Signs of neonatal sepsis
Maternal chorioamnionitis exposes the newborn to infection, so the priority is monitoring for signs of neonatal sepsis such as temperature instability, lethargy, and respiratory distress.
- Which statement about administering vitamin K to a newborn is accurate?
- It is given orally as the standard route in the hospital
- It is given to treat existing bleeding only
- It is given prophylactically to prevent hemorrhagic disease of the newborn
- It should be withheld in breastfed infants
Correct answer: It is given prophylactically to prevent hemorrhagic disease of the newborn
Newborns have low vitamin K stores and sterile guts; an intramuscular vitamin K injection is given prophylactically to prevent vitamin K deficiency bleeding (hemorrhagic disease of the newborn).
- A woman at 28 weeks reports decreased fetal movement. After applying the monitor, the nurse notes absent accelerations and minimal variability over 40 minutes. What is the appropriate next step?
- Notify the provider and prepare for further fetal evaluation
- Discontinue monitoring
- Reassure and discharge home
- Encourage the woman to walk
Correct answer: Notify the provider and prepare for further fetal evaluation
Decreased fetal movement with a nonreactive tracing and minimal variability is concerning for fetal compromise and warrants provider notification and further evaluation such as a biophysical profile.
- A nurse is teaching parents about car seat safety for a newborn. Which instruction is correct?
- Dress the infant in a bulky coat under the harness
- Add thick padding behind the infant's back
- Place the car seat forward-facing in the front seat
- Use a rear-facing car seat in the back seat
Correct answer: Use a rear-facing car seat in the back seat
Newborns should ride in a properly installed rear-facing car seat in the back seat, with the harness snug and no bulky clothing or aftermarket padding that compromise restraint effectiveness.
- A postpartum woman who delivered vaginally has a fourth-degree perineal laceration. Which nursing teaching point is most important?
- Use enemas daily to keep stool soft
- Resume intercourse immediately
- Avoid rectal suppositories and enemas; use stool softeners and sitz baths
- Apply heat to the perineum in the first 24 hours
Correct answer: Avoid rectal suppositories and enemas; use stool softeners and sitz baths
A fourth-degree laceration involves the anal sphincter and rectal mucosa; rectal interventions are contraindicated, while stool softeners and sitz baths promote comfort and healing.
- A nurse is assessing a newborn's gestational age using the Ballard score. Which finding is consistent with a term infant?
- Flat areola with no bud
- Sole creases covering the entire foot
- Abundant lanugo over the entire back
- Loose, transparent skin
Correct answer: Sole creases covering the entire foot
Sole creases covering the entire foot indicate maturity consistent with a term infant, whereas abundant lanugo, transparent skin, and flat areola suggest prematurity.
- A woman with a history of group B streptococcus colonization presents in labor. What is the appropriate intrapartum management?
- No treatment is needed
- Delay delivery until the infection clears
- Administer intrapartum antibiotic prophylaxis
- Administer antibiotics only to the newborn
Correct answer: Administer intrapartum antibiotic prophylaxis
Intrapartum antibiotic prophylaxis (commonly penicillin) for GBS-positive women reduces the risk of early-onset neonatal GBS sepsis by limiting vertical transmission during birth.
- A nurse observes that a newborn becomes cyanotic when quiet but pinks up when crying. What condition should be suspected?
- Hypoglycemia
- Normal newborn behavior
- Bilateral choanal atresia
- Transient tachypnea
Correct answer: Bilateral choanal atresia
Cyanosis at rest that improves with crying (mouth breathing) suggests bilateral choanal atresia, a nasal airway obstruction, since newborns are obligate nasal breathers.
- A postpartum patient is being discharged on day 2 and asks about resuming contraception while exclusively breastfeeding. Which method is generally preferred for a breastfeeding mother?
- High-dose estrogen patch
- Progestin-only methods
- No contraception is needed while breastfeeding
- Combined estrogen-progestin oral contraceptives
Correct answer: Progestin-only methods
Progestin-only contraceptives are preferred during breastfeeding because estrogen-containing methods can reduce milk supply, especially in the early postpartum period.
- A nurse is caring for a woman with placental abruption. Which clinical presentation is most characteristic?
- Painful dark red bleeding with a rigid, tender uterus
- Painless bright red bleeding
- No bleeding with painless contractions
- Clear fluid leakage without pain
Correct answer: Painful dark red bleeding with a rigid, tender uterus
Placental abruption typically presents with painful, often dark red bleeding and a rigid, tender uterus, in contrast to the painless bleeding of placenta previa.
- Which finding warrants further evaluation in a newborn's neurological assessment?
- Absent Moro reflex on one side
- Strong grasp reflex bilaterally
- Positive Babinski reflex
- Symmetric Moro reflex
Correct answer: Absent Moro reflex on one side
An asymmetric or absent Moro reflex on one side may indicate a clavicle fracture, brachial plexus injury, or neurological deficit and requires further evaluation.
- A nurse is assessing a postpartum woman who delivered 6 hours ago and notes her pulse is 110 and blood pressure is 96/58, with pallor and dizziness. Fundus is firm. What is the priority assessment?
- Assess for a concealed hemorrhage such as a hematoma
- Assess for caput succedaneum
- Encourage ambulation
- Document and reassess in 8 hours
Correct answer: Assess for a concealed hemorrhage such as a hematoma
Tachycardia, hypotension, pallor, and dizziness with a firm fundus suggest blood loss from a source other than atony, such as a vulvar or vaginal hematoma or concealed bleeding, requiring prompt assessment.
- A nurse is teaching a mother about expected newborn stool patterns. Which statement is accurate about a breastfed infant's stool after the first few days?
- Stools are typically loose, seedy, and yellow
- Stools are normally black and tarry after day 4
- Stools should be hard pellets
- Stools should be firm and brown
Correct answer: Stools are typically loose, seedy, and yellow
After meconium passes, the breastfed infant's stool is typically loose, seedy, and yellow. Persistent black tarry stool after day 4 may indicate retained meconium or bleeding.
- A laboring woman at 4 cm has fetal heart rate variable decelerations that recover quickly. What do variable decelerations most commonly indicate?
- Fetal sleep cycle
- Umbilical cord compression
- Uteroplacental insufficiency
- Head compression
Correct answer: Umbilical cord compression
Variable decelerations result from umbilical cord compression. Repositioning the mother to relieve cord pressure is the usual first intervention.
- A nurse is providing skin-to-skin care for a stable newborn immediately after birth. Which benefit is most directly supported by this practice?
- Delayed maternal-infant bonding
- Reduced blood glucose stability
- Improved thermoregulation and breastfeeding initiation
- Increased risk of hypothermia
Correct answer: Improved thermoregulation and breastfeeding initiation
Skin-to-skin contact stabilizes the newborn's temperature, heart rate, and blood glucose, promotes early breastfeeding, and enhances maternal-infant bonding.
- A pregnant woman at 35 weeks is diagnosed with preterm premature rupture of membranes. Which assessment is the highest priority?
- Maternal weight
- Signs of infection (maternal fever, fetal tachycardia, uterine tenderness)
- Maternal appetite
- Frequency of fetal hiccups
Correct answer: Signs of infection (maternal fever, fetal tachycardia, uterine tenderness)
With ruptured membranes, the priority is monitoring for chorioamnionitis, indicated by maternal fever, fetal tachycardia, uterine tenderness, and foul-smelling fluid.
- A nurse is reviewing the plan of care for a newborn with suspected congenital hypothyroidism detected on newborn screening. Why is early treatment essential?
- To prevent neonatal jaundice
- To reduce the need for vitamin K
- To prevent irreversible intellectual disability
- To stimulate weight loss
Correct answer: To prevent irreversible intellectual disability
Early initiation of thyroid hormone replacement in congenital hypothyroidism is essential to prevent permanent intellectual disability and growth impairment.
- A nurse is caring for a newborn whose mother is hepatitis B surface antigen positive. What intervention is indicated?
- Isolate the infant from the mother
- Delay all immunizations until 6 months
- No prophylaxis is needed
- Administer hepatitis B vaccine and hepatitis B immune globulin within 12 hours
Correct answer: Administer hepatitis B vaccine and hepatitis B immune globulin within 12 hours
Infants of hepatitis B surface antigen-positive mothers should receive both the hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth to prevent vertical transmission.
- A nurse assesses a newborn and finds a heart murmur, poor feeding, and oxygen saturation differences between the right hand and the feet. What does this suggest?
- Normal transitional circulation
- Transient tachypnea
- Physiologic anemia
- A possible critical congenital heart defect
Correct answer: A possible critical congenital heart defect
A pre- and post-ductal oxygen saturation difference (right hand higher than feet) with a murmur and poor feeding suggests a critical congenital heart defect such as coarctation, requiring urgent evaluation.
- A postpartum woman who is exclusively breastfeeding asks why she should continue prenatal vitamins. The best response is:
- They are no longer necessary after birth
- They replace the need for a balanced diet
- They support maternal nutrient stores and breast milk quality
- They prevent the baby from gaining weight
Correct answer: They support maternal nutrient stores and breast milk quality
Continuing prenatal vitamins during lactation helps maintain maternal nutrient stores and supports the nutritional quality of breast milk, alongside a balanced diet.
- A nurse is assessing a newborn's head and finds a soft swelling that crosses the suture lines and was present at birth. What does this describe?
- Cephalohematoma
- Subgaleal hemorrhage
- Caput succedaneum
- Craniosynostosis
Correct answer: Caput succedaneum
Caput succedaneum is edema of the scalp that crosses suture lines and is present at birth, resolving in a few days. A cephalohematoma does not cross suture lines.
- A woman in labor has a fetus in a breech presentation. Which complication is the nurse most concerned about during a vaginal breech delivery?
- Shoulder dystocia
- Precipitous labor
- Caput succedaneum
- Umbilical cord prolapse and head entrapment
Correct answer: Umbilical cord prolapse and head entrapment
Breech presentation increases the risk of umbilical cord prolapse and entrapment of the aftercoming head, both of which can compromise fetal oxygenation.
- A nurse identifies signs of postpartum hemorrhage and begins management. Which medication is contraindicated in a woman with hypertension?
- Tranexamic acid
- Oxytocin
- Methylergonovine
- Carboprost in a woman with asthma is preferred
Correct answer: Methylergonovine
Methylergonovine (an ergot alkaloid) causes vasoconstriction and is contraindicated in women with hypertension because it can dangerously elevate blood pressure.
- A nurse is teaching a mother about cluster feeding in a newborn. Which explanation is most accurate?
- It means the baby should be fed on a strict 4-hour schedule
- It is a normal pattern of frequent feedings, often in the evening
- It is a sign of inadequate milk supply requiring formula
- It indicates the baby is ill
Correct answer: It is a normal pattern of frequent feedings, often in the evening
Cluster feeding is a normal newborn behavior involving closely spaced feedings, often in the evening, and supports milk supply rather than indicating a problem.
- A nurse caring for a woman with severe preeclampsia should monitor for which sign of impending eclampsia?
- Polyuria
- Decreased deep tendon reflexes
- Bradycardia
- Hyperreflexia with clonus
Correct answer: Hyperreflexia with clonus
Hyperreflexia with clonus reflects CNS irritability and signals an increased risk of eclamptic seizure, prompting magnesium sulfate therapy and close monitoring.
- A newborn is diagnosed with polycythemia (hematocrit 68 percent). Which complication is the infant most at risk for?
- Dehydration only
- Hyperviscosity and hypoglycemia
- Hypertension
- Anemia
Correct answer: Hyperviscosity and hypoglycemia
Polycythemia increases blood viscosity, impairing perfusion and increasing the risk of hypoglycemia, respiratory distress, and thrombosis. Monitoring glucose and hydration is essential.
- A nurse is caring for a woman who experienced a stillbirth. Which nursing action best supports the grieving family?
- Remove all references to the infant immediately
- Avoid discussing the loss to prevent further pain
- Encourage them to focus on a future pregnancy
- Offer the option to see and hold the infant and create mementos
Correct answer: Offer the option to see and hold the infant and create mementos
Supportive perinatal bereavement care includes offering the family time with the infant and the opportunity to create mementos, which can aid the grieving process.
- A nurse is teaching a mother about newborn weight loss in the first week. Which amount of weight loss is considered within normal limits?
- No weight loss is normal
- 15 to 20 percent of birth weight
- Up to 7 to 10 percent of birth weight
- 25 percent of birth weight
Correct answer: Up to 7 to 10 percent of birth weight
A weight loss of up to 7 to 10 percent of birth weight in the first few days is normal, with most newborns regaining birth weight by 10 to 14 days.
- A nurse is preparing to administer eye prophylaxis to a newborn. What is the primary purpose of this medication?
- Improve newborn vision
- Prevent ophthalmia neonatorum from gonococcal infection
- Treat existing conjunctivitis
- Prevent retinopathy of prematurity
Correct answer: Prevent ophthalmia neonatorum from gonococcal infection
Erythromycin ophthalmic ointment is given to prevent ophthalmia neonatorum, primarily gonococcal conjunctivitis acquired during passage through the birth canal.
- A woman at 38 weeks presents with regular contractions every 4 minutes, cervical dilation of 4 cm, and a reassuring fetal heart rate. This is consistent with which stage and phase of labor?
- Third stage
- First stage, latent phase
- Second stage
- First stage, active phase
Correct answer: First stage, active phase
Active phase of the first stage of labor generally begins around 4 to 6 cm with regular, progressing contractions and cervical change, distinguishing it from the latent phase.
- A nurse notes that a newborn at 30 minutes of age has not initiated feeding and is showing rooting and hand-to-mouth movements. What do these behaviors indicate?
- The infant is ill
- The infant is showing early feeding cues
- The infant is overstimulated
- The infant requires immediate formula
Correct answer: The infant is showing early feeding cues
Rooting, hand-to-mouth movements, and lip smacking are early feeding cues, signaling readiness to feed. Responding to early cues supports successful breastfeeding before crying (a late cue) occurs.
- A postpartum woman with a history of substance use disorder is reluctant to disclose information for fear of judgment. What is the most therapeutic nursing approach?
- Confront her about her past behaviors
- Provide nonjudgmental, supportive care and connect her with resources
- Limit her contact with the infant
- Report her behavior to law enforcement automatically
Correct answer: Provide nonjudgmental, supportive care and connect her with resources
Nonjudgmental, trauma-informed care builds trust and encourages disclosure and engagement, improving outcomes for both mother and infant. Resources and support are provided as indicated.
- A nurse is caring for a newborn who suddenly becomes apneic with a heart rate dropping to 80 bpm. After stimulation fails, what is the immediate priority?
- Take an axillary temperature
- Call the parents
- Administer glucose
- Begin positive pressure ventilation
Correct answer: Begin positive pressure ventilation
Apnea with bradycardia unresponsive to stimulation requires immediate positive pressure ventilation to restore oxygenation, the cornerstone of newborn resuscitation.
- A nurse is teaching a mother about preventing newborn infection at home. Which statement indicates correct understanding?
- The baby should be taken to crowded places to build immunity
- Visitors with colds can hold the baby if they wash their hands
- Pacifiers can be cleaned by putting them in the parent's mouth
- Anyone handling the baby should wash their hands first
Correct answer: Anyone handling the baby should wash their hands first
Hand hygiene before handling the newborn is the most important infection prevention measure, given the newborn's immature immune system; sick visitors and shared oral contact should be avoided.
- A woman with twin gestation is at increased risk for which intrapartum and postpartum complication?
- Oligohydramnios
- Reduced placental size
- Postpartum hemorrhage from uterine overdistension
- Post-term pregnancy
Correct answer: Postpartum hemorrhage from uterine overdistension
Multiple gestation overdistends the uterus, increasing the risk of uterine atony and postpartum hemorrhage, along with preterm birth and other complications.
- A nurse assesses a 3-day-old newborn with feeding difficulty, lethargy, and a sweet or musty odor. Newborn metabolic screening is pending. These findings could indicate which type of disorder?
- A respiratory disorder
- A musculoskeletal disorder
- Normal newborn behavior
- An inborn error of metabolism
Correct answer: An inborn error of metabolism
Lethargy, poor feeding, and an unusual body or urine odor can indicate an inborn error of metabolism such as phenylketonuria or maple syrup urine disease, identified through newborn screening.
- A nurse provides postpartum teaching about resuming exercise after an uncomplicated vaginal delivery. Which recommendation is most appropriate?
- Start with gentle activity such as walking and progress gradually
- Begin high-intensity exercise immediately
- Resume contact sports within the first week
- Avoid all activity for 6 weeks
Correct answer: Start with gentle activity such as walking and progress gradually
After an uncomplicated vaginal birth, gentle activity like walking can begin early and progress gradually based on comfort and provider guidance, supporting recovery without overexertion.
- A nurse is monitoring a woman in labor whose membranes ruptured 20 hours ago. Which finding most strongly suggests developing infection?
- Strong regular contractions
- Clear amniotic fluid
- Maternal temperature of 38.3 C and fetal tachycardia
- Bloody show
Correct answer: Maternal temperature of 38.3 C and fetal tachycardia
Prolonged rupture of membranes increases infection risk; maternal fever with fetal tachycardia are key signs of chorioamnionitis requiring prompt treatment.
- A nurse is caring for a newborn at risk for hypoglycemia. Which is the most appropriate routine screening practice?
- Check glucose only if seizures occur
- Give intravenous dextrose to all newborns
- Withhold feedings until 12 hours of age
- Monitor blood glucose per protocol in at-risk infants and feed early
Correct answer: Monitor blood glucose per protocol in at-risk infants and feed early
At-risk infants (e.g., infants of diabetic mothers, large or small for gestational age, preterm) require scheduled glucose monitoring and early feeding to prevent and detect hypoglycemia.
- A postpartum woman develops a sudden onset of dyspnea, chest pain, and anxiety on day 2. What complication should the nurse suspect first?
- Mastitis
- Constipation
- Endometritis
- Pulmonary embolism
Correct answer: Pulmonary embolism
The postpartum hypercoagulable state increases thromboembolism risk. Sudden dyspnea, chest pain, and anxiety suggest pulmonary embolism, a life-threatening emergency requiring immediate action.
- A nurse is teaching about umbilical cord stump signs that require provider notification. Which finding should the parent report?
- Foul odor, purulent drainage, and surrounding redness
- Slight darkening and drying of the stump
- Separation of the cord around day 10
- Small amount of dried blood at separation
Correct answer: Foul odor, purulent drainage, and surrounding redness
Foul odor, purulent discharge, and periumbilical redness indicate omphalitis (cord infection) and must be reported. Drying, darkening, and separation around 1 to 2 weeks are normal.
- A laboring woman experiences shoulder dystocia after the fetal head delivers. Which maneuver is the first-line intervention?
- McRoberts maneuver with suprapubic pressure
- Immediate cesarean
- Forceps to the shoulders
- Fundal pressure
Correct answer: McRoberts maneuver with suprapubic pressure
The McRoberts maneuver (sharp flexion of maternal hips onto the abdomen) combined with suprapubic pressure is the first-line response to shoulder dystocia. Fundal pressure is contraindicated.
- A nurse is assessing attachment behaviors in a new mother. Which behavior is a positive indicator of bonding?
- Calling the infant by name and making eye contact
- Avoiding eye contact with the infant
- Expressing disinterest during feeding
- Asking others to provide all care
Correct answer: Calling the infant by name and making eye contact
Positive attachment behaviors include calling the infant by name, making eye contact (en face position), and engaging in care, indicating healthy maternal-infant bonding.
- A nurse is reviewing care for a newborn born at 41 weeks plus 3 days. Which finding is characteristic of a post-term infant?
- Transparent skin
- Dry, cracked, peeling skin with long nails
- Abundant vernix and lanugo
- Fused eyelids
Correct answer: Dry, cracked, peeling skin with long nails
Post-term infants often show dry, cracked, peeling skin, long fingernails, and decreased vernix due to prolonged exposure to the intrauterine environment.
- A woman with gestational hypertension is being monitored. Which laboratory or assessment change suggests progression to preeclampsia?
- New onset of significant proteinuria
- Increased urine output
- Weight loss
- Decreased blood pressure
Correct answer: New onset of significant proteinuria
Preeclampsia is distinguished from gestational hypertension by the new onset of proteinuria (or other end-organ signs) after 20 weeks of gestation.
- A nurse is teaching a mother how to wake a sleepy newborn for feeding. Which technique is most appropriate?
- Force the bottle into the baby's mouth
- Submerge the baby in cool water
- Wait until the baby wakes on its own regardless of time
- Unwrap the baby, change the diaper, and provide skin-to-skin contact
Correct answer: Unwrap the baby, change the diaper, and provide skin-to-skin contact
Gentle arousal techniques such as unwrapping, diaper changes, and skin-to-skin contact help wake a sleepy newborn for feeding while avoiding harmful or distressing methods.
- A newborn is found to have a sacral dimple with a tuft of hair. What does this finding warrant?
- Evaluation for an underlying spinal abnormality
- No further evaluation
- Immediate surgery
- Antibiotic therapy
Correct answer: Evaluation for an underlying spinal abnormality
A sacral dimple with a hair tuft can be a cutaneous marker of occult spinal dysraphism (such as spina bifida occulta) and warrants further evaluation such as ultrasound.
- A nurse is caring for a woman in labor with a known abruption and signs of disseminated intravascular coagulation. Which laboratory finding is consistent with DIC?
- Elevated platelet count and low D-dimer
- Normal coagulation studies
- Elevated fibrinogen with normal platelets
- Decreased fibrinogen, prolonged PT/PTT, and elevated D-dimer
Correct answer: Decreased fibrinogen, prolonged PT/PTT, and elevated D-dimer
DIC is characterized by consumption of clotting factors, resulting in decreased fibrinogen and platelets, prolonged PT/PTT, and elevated D-dimer and fibrin degradation products.
- A nurse provides anticipatory guidance about newborn vision. Which statement is accurate?
- Newborns see best at distances greater than 3 feet
- Newborns focus best at about 8 to 12 inches, ideal for face viewing during feeding
- Newborns cannot perceive any light or shapes
- Newborns have full adult visual acuity at birth
Correct answer: Newborns focus best at about 8 to 12 inches, ideal for face viewing during feeding
Newborns focus best at about 8 to 12 inches, roughly the distance to a caregiver's face during feeding, which supports early visual engagement and bonding.
- A nurse is assessing a newborn for signs of adequate hydration. Which finding indicates dehydration requiring evaluation?
- Brisk capillary refill
- Moist mucous membranes
- Six wet diapers per day
- Sunken fontanelle and decreased wet diapers
Correct answer: Sunken fontanelle and decreased wet diapers
A sunken fontanelle, dry mucous membranes, and decreased urine output indicate dehydration in a newborn, requiring prompt assessment of feeding adequacy and possible intervention.
- A nurse is reviewing maternal postpartum cardiovascular changes. Which finding is expected in the first 48 hours after delivery?
- Transient increase in cardiac output and diuresis
- Severe tachycardia at rest
- Decreased cardiac output and bradycardia
- Persistent hypertension in all women
Correct answer: Transient increase in cardiac output and diuresis
After delivery, autotransfusion from the contracted uterus and mobilization of extravascular fluid cause a transient rise in cardiac output and marked diuresis as the body eliminates excess fluid.
- A nurse is teaching a mother of a newborn diagnosed with a cleft lip and palate about feeding. Which adaptation is most appropriate?
- Use a specialized cleft palate nipple or bottle and hold the infant upright
- Use a standard nipple with rapid flow
- Feed only in the supine flat position
- Withhold feeds until surgical repair
Correct answer: Use a specialized cleft palate nipple or bottle and hold the infant upright
Infants with cleft palate cannot generate adequate suction, so specialized nipples or bottles and an upright feeding position help deliver milk and reduce aspiration and nasal regurgitation.
- A woman in active labor suddenly becomes hypotensive, hypoxic, and develops coagulopathy and cardiovascular collapse shortly after rupture of membranes. What is the most likely emergency?
- Braxton Hicks contractions
- Normal labor progression
- Amniotic fluid embolism
- Mild dehydration
Correct answer: Amniotic fluid embolism
Amniotic fluid embolism is a rare, catastrophic event presenting with sudden cardiorespiratory collapse, hypoxia, and coagulopathy, requiring immediate resuscitation and supportive care.
- A nurse assesses a postpartum woman and finds the fundus is two fingerbreadths below the umbilicus on day 2. How should the nurse interpret this finding?
- Retained placenta
- Expected involution progression
- Subinvolution requiring intervention
- Uterine atony
Correct answer: Expected involution progression
The fundus descends approximately one fingerbreadth per day after delivery. Being two fingerbreadths below the umbilicus on day 2 reflects normal, expected uterine involution.
- A nurse is monitoring a newborn for signs of necrotizing enterocolitis. Which assessment finding is most concerning?
- Regular feeding pattern
- Normal bowel sounds
- Soft, nondistended abdomen
- Abdominal distension, bloody stools, and feeding intolerance
Correct answer: Abdominal distension, bloody stools, and feeding intolerance
Necrotizing enterocolitis presents with abdominal distension, feeding intolerance, and bloody stools, most often in preterm infants, and requires prompt evaluation and intervention.
- A nurse is teaching a postpartum woman experiencing engorgement who plans to continue breastfeeding. Which recommendation is appropriate?
- Stop breastfeeding for 24 hours
- Feed frequently and apply cold compresses between feedings
- Apply heat for prolonged periods between feeds
- Bind the breasts tightly and avoid feeding
Correct answer: Feed frequently and apply cold compresses between feedings
For a breastfeeding mother, frequent feeding relieves engorgement, while cold compresses between feedings reduce swelling and discomfort. Brief warmth before feeding may aid let-down.
- A nurse is assessing a term newborn 5 minutes after birth. The infant is now crying vigorously, fully flexed, with a heart rate of 150 and pink color, sneezing with suction. What is the 5-minute Apgar score?
Correct answer: 10
Heart rate >100 = 2, vigorous cry = 2, active flexion = 2, sneeze (grimace response) = 2, completely pink = 2, totaling a perfect score of 10.
- A nurse caring for a woman with preeclampsia plans to reduce environmental stimulation. What is the rationale for this intervention?
- To conserve hospital resources
- To limit family visits unnecessarily
- To reduce the risk of provoking a seizure
- To promote earlier discharge
Correct answer: To reduce the risk of provoking a seizure
A quiet, low-stimulation environment reduces CNS irritability and lowers the risk of provoking an eclamptic seizure in a woman with preeclampsia.
- A nurse is teaching a new mother about when to introduce solid foods. Which recommendation is correct?
- Add cereal to bottles in the first week
- Avoid solids until 12 months
- Begin solids at 2 months of age
- Introduce solids around 6 months when developmental readiness signs appear
Correct answer: Introduce solids around 6 months when developmental readiness signs appear
Solid foods are recommended around 6 months of age when the infant shows developmental readiness, while exclusive breastfeeding or formula is recommended before then.
- A woman who delivered 30 minutes ago has not yet delivered the placenta. The provider notes signs of placental separation. Which sign indicates the placenta has separated?
- Cessation of all bleeding
- A gush of blood, lengthening of the cord, and the uterus rising and firming
- Decreased fundal height
- The uterus becomes soft and boggy
Correct answer: A gush of blood, lengthening of the cord, and the uterus rising and firming
Signs of placental separation include a sudden gush of blood, lengthening of the umbilical cord, and the uterus rising in the abdomen and becoming globular and firm.
- A nurse is providing care for a newborn at risk for hypothermia in a radiant warmer. Which nursing action helps prevent overheating?
- Use a servo-controlled skin temperature probe
- Position the warmer near a heating vent
- Cover the infant with multiple blankets under the warmer
- Set the warmer to maximum continuously
Correct answer: Use a servo-controlled skin temperature probe
A servo-controlled skin probe adjusts the radiant warmer output to maintain a set skin temperature, preventing both hypothermia and hyperthermia.
- A nurse reviews the medication list of a breastfeeding mother. Which medication concern most warrants consultation before the mother continues breastfeeding?
- Acetaminophen for pain
- Prenatal vitamins
- Docusate sodium stool softener
- A medication contraindicated during lactation
Correct answer: A medication contraindicated during lactation
Some medications are contraindicated during lactation due to transfer into breast milk and potential infant harm; these require consultation and possibly an alternative before continuing breastfeeding.
- A nurse is assessing a postpartum woman who reports feeling tearful, irritable, and overwhelmed on day 3, but is still caring for and bonding with her infant. These symptoms are most consistent with:
- Bipolar disorder
- Postpartum blues (baby blues)
- Postpartum psychosis
- Postpartum depression
Correct answer: Postpartum blues (baby blues)
Postpartum blues are common, transient mood changes (tearfulness, irritability) peaking around days 3 to 5 and resolving within 2 weeks without impairing infant care, distinct from postpartum depression.
- A nurse is preparing a newborn for circumcision. Which assessment finding is a contraindication requiring provider notification before the procedure?
- Normal voiding pattern
- Normal penile anatomy
- Hypospadias
- Stable vital signs
Correct answer: Hypospadias
Hypospadias is a contraindication to routine circumcision because the foreskin may be needed for surgical repair of the urethral opening, so the procedure should be deferred.
- A nurse is teaching parents pain and comfort measures for a newborn after circumcision. Which instruction is appropriate?
- Submerge the infant in a tub bath immediately
- Remove the petroleum gauze with each diaper change forcefully
- Apply petroleum jelly to the site and watch for signs of bleeding or infection
- Use alcohol wipes on the site
Correct answer: Apply petroleum jelly to the site and watch for signs of bleeding or infection
Applying petroleum jelly protects the healing glans, and parents should monitor for bleeding, signs of infection, and adequate urination while avoiding alcohol and immediate tub baths.
- A nurse is assessing a newborn's respiratory status and counts respirations over a full minute. Which respiratory rate is within normal limits for a quiet newborn?
- 75 breaths per minute
- 45 breaths per minute
- 20 breaths per minute
- 90 breaths per minute
Correct answer: 45 breaths per minute
The normal newborn respiratory rate is 30 to 60 breaths per minute. A rate of 45 is within normal limits; rates below 30 or above 60 require further assessment.
- A nurse is caring for a postpartum patient and notes the woman is reluctant to make decisions and defers to her partner for all infant care choices. What is the most culturally sensitive nursing response?
- Insist the mother make all decisions independently
- Exclude the partner from teaching
- Assess and respect the family's decision-making structure while ensuring informed care
- Document the mother as noncompliant
Correct answer: Assess and respect the family's decision-making structure while ensuring informed care
Decision-making structures vary across cultures and families. The nurse respects the family's preferred process while ensuring that care decisions are informed and safe.
- A nurse identifies that a newborn has a positive transillumination of the scrotum. What does this finding most likely indicate?
- Hydrocele
- Testicular torsion
- Inguinal hernia with bowel
- Undescended testis
Correct answer: Hydrocele
A hydrocele, a fluid collection around the testis, transilluminates (light passes through), is usually benign, and often resolves spontaneously, unlike a hernia containing bowel.
- A nurse is reviewing the postpartum care of a woman with a previous cesarean attempting a vaginal birth after cesarean. Which sign suggests uterine rupture?
- Mild lower back ache
- Sudden severe abdominal pain, loss of fetal station, and abnormal fetal heart rate
- Bloody show
- Regular strong contractions
Correct answer: Sudden severe abdominal pain, loss of fetal station, and abnormal fetal heart rate
Uterine rupture during labor may present with sudden severe abdominal pain, loss of fetal station, fetal heart rate abnormalities, and signs of hemorrhage, requiring emergency intervention.
- A nurse is teaching about newborn jaundice at home. Which instruction helps parents know when to seek care?
- All jaundice resolves on its own and never needs care
- Jaundice spreading to the arms and legs or poor feeding should be reported
- Sunlight exposure cures all jaundice
- Jaundice only matters in formula-fed infants
Correct answer: Jaundice spreading to the arms and legs or poor feeding should be reported
Parents should report jaundice that spreads beyond the face and trunk to the extremities, poor feeding, or lethargy, as these may indicate rising bilirubin requiring evaluation.
- A nurse is caring for a newborn with suspected congenital cytomegalovirus infection. Which finding is consistent with this congenital infection?
- Macrosomia
- Post-term skin changes
- Isolated clubfoot
- Microcephaly, petechiae, and hepatosplenomegaly
Correct answer: Microcephaly, petechiae, and hepatosplenomegaly
Congenital cytomegalovirus infection can cause microcephaly, petechiae, hepatosplenomegaly, jaundice, and sensorineural hearing loss, warranting evaluation and follow-up.
- A nurse is teaching a postpartum woman about Kegel exercises. What is the primary purpose of these exercises?
- Increase milk supply
- Strengthen pelvic floor muscles to improve continence and healing
- Promote weight loss
- Strengthen abdominal muscles
Correct answer: Strengthen pelvic floor muscles to improve continence and healing
Kegel exercises strengthen the pelvic floor muscles, helping restore muscle tone, improve urinary continence, and support perineal healing after childbirth.
- A nurse is monitoring a preterm newborn for retinopathy of prematurity. Which factor most increases the risk of this condition?
- Phototherapy
- Prolonged high concentrations of supplemental oxygen
- Skin-to-skin contact
- Breastfeeding
Correct answer: Prolonged high concentrations of supplemental oxygen
Retinopathy of prematurity is associated with prematurity and prolonged exposure to high oxygen concentrations, which can cause abnormal retinal vessel development; oxygen is carefully titrated.
- A nurse is caring for a woman in the latent phase of labor who is anxious and asks about coping techniques. Which nonpharmacologic measure is appropriate to suggest?
- Restricting all fluids
- Breathing techniques, position changes, and ambulation
- Holding the breath during contractions
- Lying flat and still for hours
Correct answer: Breathing techniques, position changes, and ambulation
Nonpharmacologic comfort measures such as patterned breathing, frequent position changes, ambulation, and relaxation techniques help manage early labor discomfort and anxiety.
- A nurse assesses a newborn 4 hours after a vacuum-assisted delivery and notes a firm, well-defined swelling on the scalp that does not cross suture lines. What does this finding describe?
- Molding
- Cephalohematoma
- Caput succedaneum
- Normal scalp
Correct answer: Cephalohematoma
A cephalohematoma is a collection of blood between the periosteum and skull that does not cross suture lines and may appear or enlarge after birth, often associated with instrument delivery.
- A nurse is teaching a mother to recognize signs of illness in her newborn requiring prompt medical attention. Which sign should the nurse emphasize?
- Passing several stools per day
- Sneezing once or twice
- Occasional hiccups
- A rectal temperature of 38 C or higher or poor feeding with lethargy
Correct answer: A rectal temperature of 38 C or higher or poor feeding with lethargy
A fever (38 C or higher) in a newborn, along with poor feeding and lethargy, can indicate serious infection and requires prompt medical evaluation. Hiccups and sneezing are normal.
- A nurse is caring for a woman with intrahepatic cholestasis of pregnancy. Which symptom is the hallmark of this condition?
- Sudden severe headache
- Severe generalized pruritus, especially on the palms and soles
- Painless vaginal bleeding
- Profuse watery diarrhea
Correct answer: Severe generalized pruritus, especially on the palms and soles
Intrahepatic cholestasis of pregnancy causes intense pruritus (notably of the palms and soles) due to elevated bile acids and is associated with increased fetal risk requiring surveillance.
- A nurse is teaching a postpartum mother about emotional adjustment and when to seek help. Which statement by the mother indicates she understands when professional help is needed?
- Feeling sad for months is normal and never needs attention
- I should call my provider if sad feelings last more than 2 weeks or worsen
- Only physical problems need a provider
- I should stop breastfeeding if I feel sad at all
Correct answer: I should call my provider if sad feelings last more than 2 weeks or worsen
Mood symptoms that persist beyond 2 weeks, worsen, or interfere with functioning may indicate postpartum depression and warrant professional evaluation, reflecting correct understanding.
- A nurse is assessing a newborn and observes a high-pitched, shrill cry, a bulging anterior fontanelle, and irritability. These findings most suggest:
- Hunger
- Mild dehydration
- Normal newborn behavior
- Increased intracranial pressure
Correct answer: Increased intracranial pressure
A high-pitched shrill cry with a bulging anterior fontanelle and irritability suggests increased intracranial pressure, which requires prompt neurological evaluation.
- A nurse is caring for a woman with a postpartum hemorrhage who has received uterotonics with limited response. Which assessment best determines ongoing blood loss severity?
- Only visual estimation of pads
- Patient's verbal report alone
- Fundal height only
- Quantitative blood loss measurement plus vital signs and symptoms
Correct answer: Quantitative blood loss measurement plus vital signs and symptoms
Quantitative blood loss measurement combined with vital signs and clinical symptoms (e.g., tachycardia, hypotension, altered consciousness) provides a more accurate assessment than visual estimation alone.
- A nurse is teaching parents of a newborn about the function of brown adipose tissue. Which statement is accurate?
- It generates heat through nonshivering thermogenesis
- It stores excess calories for later use
- It produces antibodies
- It aids in digestion
Correct answer: It generates heat through nonshivering thermogenesis
Brown adipose tissue (brown fat) is unique to newborns and generates heat through nonshivering thermogenesis, a key mechanism for maintaining body temperature since newborns cannot shiver effectively.
- A nurse is reviewing transition physiology. Which event triggers closure of the foramen ovale after birth?
- Persistent fetal circulation
- Increased left atrial pressure relative to right atrial pressure
- Cord clamping causing decreased systemic resistance
- Increased pulmonary vascular resistance
Correct answer: Increased left atrial pressure relative to right atrial pressure
With lung expansion, pulmonary blood flow increases and left atrial pressure rises above right atrial pressure, functionally closing the foramen ovale during transition to extrauterine circulation.
- A nurse is caring for a woman receiving terbutaline for preterm labor. Which maternal side effect should the nurse monitor for?
- Hypothermia
- Bradycardia
- Tachycardia and tremors
- Hypertension and constipation
Correct answer: Tachycardia and tremors
Terbutaline, a beta-adrenergic agonist tocolytic, commonly causes maternal tachycardia, palpitations, and tremors; the nurse monitors heart rate and signs of cardiovascular compromise.
- A nurse provides discharge teaching about newborn bathing. Which instruction is most appropriate?
- Give sponge baths until the cord stump falls off and the area heals
- Give a full tub bath daily before the cord falls off
- Use hot water to clean thoroughly
- Bathe the newborn immediately after every feeding
Correct answer: Give sponge baths until the cord stump falls off and the area heals
Sponge baths are recommended until the umbilical cord stump separates and the area heals, after which tub baths can begin, using warm (not hot) water and avoiding excessive bathing.
- A nurse is assessing a woman 1 hour postpartum who received general anesthesia for an emergency cesarean. Which assessment is the highest priority?
- Airway, breathing, and level of consciousness
- Dietary preferences
- Visitor list
- Birth plan review
Correct answer: Airway, breathing, and level of consciousness
After general anesthesia, the immediate priority is airway patency, adequate breathing, and level of consciousness, as anesthesia recovery carries risks of airway compromise and respiratory depression.
- A nurse is caring for a newborn whose mother had poorly controlled diabetes. Besides hypoglycemia, which complication should the nurse monitor for?
- Hypocalcemia and respiratory distress
- Anemia only
- Hyperthermia
- Post-term skin changes
Correct answer: Hypocalcemia and respiratory distress
Infants of diabetic mothers are at risk for hypoglycemia, hypocalcemia, polycythemia, hyperbilirubinemia, and respiratory distress syndrome due to delayed lung maturity.
- A nurse is teaching a mother about the rooting and sucking reflexes and feeding. Which statement reflects appropriate understanding of feeding on demand?
- I should feed strictly every 4 hours by the clock
- I should only feed when the baby cries hard
- I will limit feedings to 5 minutes each
- I will feed my baby when I see early hunger cues, about 8 to 12 times a day
Correct answer: I will feed my baby when I see early hunger cues, about 8 to 12 times a day
Feeding on demand in response to early hunger cues, typically 8 to 12 times per 24 hours for a newborn, supports adequate intake and milk supply better than rigid scheduling.
- A nurse is monitoring a newborn at risk for hemorrhagic disease who did not receive vitamin K. Which finding would be consistent with vitamin K deficiency bleeding?
- Increased appetite
- Excessive sleeping only
- Unexplained bruising, bleeding from the cord, or blood in the stool
- Rapid weight gain
Correct answer: Unexplained bruising, bleeding from the cord, or blood in the stool
Vitamin K deficiency bleeding presents with unexplained bruising, prolonged bleeding from the umbilical stump or circumcision site, and gastrointestinal bleeding due to deficient clotting factors.
- A nurse is teaching a mother about tummy time. Which instruction is correct?
- Supervised tummy time while awake helps strengthen neck and shoulder muscles
- The baby should sleep on the stomach to get used to tummy time
- Tummy time should be done while the baby sleeps
- Tummy time is unnecessary and should be avoided
Correct answer: Supervised tummy time while awake helps strengthen neck and shoulder muscles
Supervised tummy time while the infant is awake promotes development of neck, shoulder, and trunk strength and helps prevent positional plagiocephaly, while sleep remains supine.
- A nurse is caring for a woman in labor with a category III fetal heart rate tracing showing absent variability with recurrent late decelerations. After initial interventions fail, what is the expected management?
- Reduce monitoring frequency
- Discharge the patient home
- Continue to observe without action
- Prepare for expedited delivery
Correct answer: Prepare for expedited delivery
A category III tracing reflects abnormal fetal acid-base status. If intrauterine resuscitation measures do not resolve it, expedited delivery (operative vaginal or cesarean) is indicated.
- A nurse is reviewing newborn nutrition and recognizes that human milk provides immunologic protection primarily through which component?
- Added vitamin D fortification
- Secretory immunoglobulin A (IgA)
- High iron concentration
- High sodium content
Correct answer: Secretory immunoglobulin A (IgA)
Secretory IgA in human milk, especially abundant in colostrum, coats the infant's gastrointestinal and respiratory mucosa, providing passive immunity and protection against infection.
- A nurse assesses a woman 12 hours after a vaginal birth. The fundus is firm but is located two fingerbreadths above the umbilicus and deviated to the right of midline. What is the most likely cause of this finding?
- Normal involution for this point postpartum
- Beginning uterine atony requiring oxytocin
- Retained placental fragments
- A distended bladder displacing the uterus
Correct answer: A distended bladder displacing the uterus
A distended bladder is the most likely cause when a firm fundus rises above the umbilicus and shifts to the right of midline. A full bladder pushes the uterus up and to the side and can also prevent the uterus from contracting effectively. The fundus should be firm, midline, and at or near the umbilicus in the first 24 hours, so the nurse should have the woman void or catheterize and then reassess. Atony produces a boggy, soft fundus rather than a firm one, so it is not the cause here.
- During a fundal assessment on the first postpartum day, where should the nurse expect the fundus to be located in a woman with normal involution?
- No longer palpable above the symphysis pubis
- At the level of the umbilicus
- Halfway between the umbilicus and symphysis pubis
- Two fingerbreadths above the umbilicus
Correct answer: At the level of the umbilicus
At or about the level of the umbilicus is the expected fundal position roughly the first 24 hours after birth. The uterus then involutes approximately one centimeter (one fingerbreadth) per day, so it descends about one fingerbreadth below the umbilicus each day and is typically no longer palpable abdominally by about postpartum day 10. A fundus that remains above the umbilicus beyond the first day suggests subinvolution or a full bladder.
- A nurse is teaching a postpartum woman about the normal progression of lochia. Which sequence accurately describes the expected color changes over time?
- Alba (white) then rubra (red) then serosa (brown)
- Rubra (red) then alba (white) then serosa (brown)
- Serosa (brown) then rubra (red) then alba (white)
- Rubra (red) then serosa (pinkish-brown) then alba (creamy white)
Correct answer: Rubra (red) then serosa (pinkish-brown) then alba (creamy white)
Lochia normally progresses from rubra to serosa to alba. Lochia rubra is dark to bright red and lasts roughly the first 1 to 4 days, lochia serosa is pinkish-brown and lasts from about day 4 to day 10, and lochia alba is creamy white to yellowish and may persist for several weeks. A return to bright red bleeding after lochia has lightened can signal subinvolution or retained placental tissue.
- A woman 3 days postpartum reports her vaginal discharge has changed from red to a pinkish-brown color and has decreased in amount. What is the nurse's best response?
- Notify the provider because this suggests retained placenta
- Reassure her that this is the expected transition to lochia serosa
- Instruct her to apply ice packs to slow the bleeding
- Explain that bright red bleeding should still be present at this stage
Correct answer: Reassure her that this is the expected transition to lochia serosa
Reassurance that this is the normal transition to lochia serosa is the best response. By about day 4, lochia normally changes from rubra (red) to serosa (pinkish to brownish) as the amount tapers, reflecting healing of the placental site. A change toward serosa is expected and reassuring, whereas a renewed flow of bright red lochia or foul odor would warrant provider notification.
- A nurse uses the acronym REEDA to evaluate a postpartum perineum. Which set of parameters does REEDA assess?
- Redness, eversion, ecchymosis, dryness, and apposition
- Redness, exudate, erythema, drainage, and alignment
- Rubor, edema, erosion, dehiscence, and adhesion
- Redness, edema, ecchymosis, discharge, and approximation
Correct answer: Redness, edema, ecchymosis, discharge, and approximation
REEDA stands for redness, edema, ecchymosis, discharge, and approximation. It is a structured tool for assessing perineal or episiotomy/laceration healing, with higher scores indicating greater inflammation and poorer healing. Well-approximated wound edges with minimal redness, edema, ecchymosis, and discharge indicate normal healing.
- A woman who had a midline episiotomy reports significant perineal pain on the first postpartum day. Which intervention is most appropriate at this time?
- Massage the perineum to improve circulation
- Apply moist heat with a sitz bath immediately after delivery
- Encourage prolonged sitting to keep pressure off the area
- Apply an ice pack to the perineum for the first 24 hours
Correct answer: Apply an ice pack to the perineum for the first 24 hours
Applying an ice pack to the perineum during the first 24 hours is most appropriate because cold reduces edema and provides analgesia by numbing the area and limiting swelling at the site of trauma. Warm sitz baths are beneficial later, generally after the first 24 hours, to promote circulation and comfort once acute swelling has peaked. Perineal massage is not used postpartum to manage episiotomy pain.
- A multiparous woman who is breastfeeding reports intermittent cramping abdominal pain that intensifies during nursing. What is the most accurate explanation the nurse can provide?
- Afterpains from oxytocin-stimulated uterine contractions, which are stronger in multiparas and during breastfeeding
- Bladder spasms from urinary retention
- Trapped intestinal gas common after birth
- Early signs of endometritis that require antibiotics
Correct answer: Afterpains from oxytocin-stimulated uterine contractions, which are stronger in multiparas and during breastfeeding
Afterpains caused by oxytocin-stimulated uterine contractions best explain the cramping. Suckling triggers oxytocin release, which causes the uterus to contract; afterpains are more pronounced in multiparas because their uterine tone is reduced and the muscle relaxes and contracts intermittently rather than staying steadily contracted. Afterpains are normal and aid involution and hemostasis, so reassurance and analgesia are appropriate.
- An Rh-negative woman who is not sensitized gives birth to an Rh-positive infant. To prevent Rh alloimmunization, when should Rho(D) immune globulin (RhoGAM) be administered postpartum?
- Within 7 days of delivery
- At the 6-week postpartum visit
- Within 72 hours of delivery
- Within 2 hours of delivery
Correct answer: Within 72 hours of delivery
Rho(D) immune globulin should be given within 72 hours of delivery to an unsensitized Rh-negative woman who delivers an Rh-positive infant. The injection provides passive antibody that destroys fetal Rh-positive cells in the maternal circulation before the mother can mount her own immune response, preventing sensitization that could harm future Rh-positive pregnancies. The standard postpartum dose is 300 micrograms IM or IV.
- A postpartum woman's prenatal record shows she is rubella non-immune. The nurse anticipates that the MMR vaccine will be given before discharge. What essential education must accompany this immunization?
- Expect a positive rubella titer immediately
- Stop breastfeeding for 1 week after the vaccine
- Avoid contact with the newborn for 72 hours
- Avoid becoming pregnant for at least 1 month after the vaccine
Correct answer: Avoid becoming pregnant for at least 1 month after the vaccine
Advising the woman to avoid pregnancy for at least 1 month after the MMR vaccine is essential because the rubella component is a live attenuated virus that poses a theoretical risk of congenital rubella if pregnancy occurs too soon. The postpartum period is an ideal time to immunize a non-immune woman. Breastfeeding is not contraindicated with MMR, so the mother can continue to nurse.
- A nurse is assessing a woman 2 hours after a vaginal birth and finds the fundus boggy, displaced above the umbilicus, with a steady trickle of bright red lochia. What is the nurse's priority action?
- Increase the IV fluid rate and recheck in 30 minutes
- Massage the fundus until firm and assess the bladder
- Administer a stool softener
- Place the woman in reverse Trendelenburg position
Correct answer: Massage the fundus until firm and assess the bladder
Massaging the fundus until it becomes firm and assessing the bladder is the priority. A boggy (soft) uterus indicates uterine atony, the leading cause of early postpartum hemorrhage, and fundal massage stimulates contraction to compress bleeding vessels. A distended bladder can prevent the uterus from contracting, so ensuring the bladder is empty supports tone. If atony persists despite massage and an empty bladder, uterotonic medication is indicated.
- A woman who gave birth 6 hours ago has not voided since delivery and reports a sensation of fullness. The fundus is firm but displaced to the right and elevated. Why is postpartum urinary retention a significant concern?
- A full bladder can displace the uterus and contribute to uterine atony and hemorrhage
- Retention permanently damages the bladder detrusor muscle
- It indicates the woman needs immediate dialysis
- It is a reliable early sign of a urinary tract infection
Correct answer: A full bladder can displace the uterus and contribute to uterine atony and hemorrhage
A full bladder can displace the uterus and contribute to atony and hemorrhage, which is why postpartum retention is a priority concern. After birth, decreased bladder tone and perineal edema or trauma can blunt the urge to void, allowing the bladder to overfill and push the uterus up and to the side, preventing effective contraction. Encouraging early voiding, and catheterizing if needed, restores uterine position and tone.
- A nurse is teaching a first-time mother about expected postpartum diuresis and diaphoresis during the first few days after birth. What is the physiologic basis for these changes?
- An infection is causing fluid shifts and sweating
- The body eliminates the excess fluid volume accumulated during pregnancy
- The kidneys are failing and retaining nitrogenous waste
- Oxytocin is causing the body to retain sodium and water
Correct answer: The body eliminates the excess fluid volume accumulated during pregnancy
Postpartum diuresis and diaphoresis occur as the body eliminates the excess fluid volume that accumulated during pregnancy. Plasma volume expands substantially in pregnancy, and after birth the drop in progesterone and the loss of placental circulation prompt the kidneys to excrete the surplus, producing copious urine output and profuse sweating, often at night, during the first 2 to 3 days. These are normal, expected findings, not signs of infection or renal failure.
- A breastfeeding woman 3 days postpartum reports her breasts are hard, warm, and painfully full, and the infant is having difficulty latching. She is afebrile. Which education is most appropriate for managing this engorgement?
- Stop breastfeeding for 24 hours to let the breasts rest
- Begin antibiotics immediately for presumed mastitis
- Nurse frequently and use warmth before feeding with cold compresses between feedings
- Apply tight binding and avoid breast stimulation completely
Correct answer: Nurse frequently and use warmth before feeding with cold compresses between feedings
Frequent nursing with warmth before feeds (to encourage letdown) and cold compresses between feeds (to reduce swelling) is the appropriate management of engorgement. Bilateral, painful fullness without fever around day 3 reflects physiologic engorgement as milk comes in; continued frequent emptying relieves it. Stopping breastfeeding or binding the breasts worsens engorgement, and antibiotics are not indicated without signs of mastitis such as fever and a localized red, tender area.
- A nurse is teaching a new mother to assess for an effective latch during breastfeeding. Which finding indicates the infant is latched correctly?
- The infant's mouth covers a large portion of the areola with lips flanged outward
- The infant's cheeks dimple inward with each suck
- The infant's lips are pursed tightly around only the nipple
- The mother hears clicking sounds and feels pinching pain throughout the feeding
Correct answer: The infant's mouth covers a large portion of the areola with lips flanged outward
A wide latch in which the infant's mouth covers much of the areola with the lips flanged outward indicates a correct, deep latch. This position lets the infant compress the milk ducts beneath the areola, transfers milk effectively, and protects the nipple from trauma. Clicking sounds, dimpled cheeks, and latching on the nipple only suggest a shallow latch that causes pain and poor milk transfer and should be corrected by repositioning.
- A postpartum woman who is bottle-feeding asks how to relieve breast discomfort as her milk comes in. What is the most appropriate instruction?
- Apply warm compresses and massage the breasts frequently
- Express a small amount of milk after each shower to soften the breasts
- Pump the breasts every 3 hours to relieve the pressure
- Wear a supportive bra, avoid breast stimulation, and apply cold compresses
Correct answer: Wear a supportive bra, avoid breast stimulation, and apply cold compresses
For a woman who is not breastfeeding, a supportive bra, avoidance of nipple and breast stimulation, and cold compresses are recommended to suppress lactation and ease engorgement discomfort. Heat, pumping, massage, and milk expression stimulate further milk production and prolong engorgement, so they should be avoided. Cabbage leaves and analgesics may also provide comfort while the milk supply diminishes.
- A nurse is evaluating a postpartum woman's vital signs on the first day after a vaginal birth. Which finding is a normal physiologic adaptation rather than a warning sign?
- A temperature of 39.2 degrees Celsius
- A respiratory rate of 28 breaths per minute
- A heart rate of 58 beats per minute
- A blood pressure of 88/50 mmHg with dizziness
Correct answer: A heart rate of 58 beats per minute
A heart rate of 58 beats per minute is a normal finding; postpartum bradycardia of about 50 to 70 beats per minute is common during the first several days due to increased cardiac stroke volume and the drop in cardiac demand after birth. A temperature of 39.2 degrees Celsius exceeds the benign 38 degrees Celsius first-24-hour threshold and suggests infection, tachypnea may signal embolism or hemorrhage, and hypotension with dizziness suggests blood loss, all of which require evaluation.
- A woman has a temperature of 38.0 degrees Celsius (100.4 degrees Fahrenheit) 8 hours after a vaginal birth, with otherwise normal assessment findings. What is the most appropriate nursing action?
- Initiate broad-spectrum antibiotics for puerperal infection
- Notify the provider immediately for suspected sepsis
- Place the woman on contact isolation
- Encourage oral fluids and reassess, as mild fever in the first 24 hours is often from dehydration
Correct answer: Encourage oral fluids and reassess, as mild fever in the first 24 hours is often from dehydration
Encouraging fluids and reassessing is appropriate because a temperature up to 38.0 degrees Celsius within the first 24 hours after birth is frequently caused by dehydration and the exertion of labor rather than infection. The classic definition of puerperal (postpartum) fever is a temperature of 38.0 degrees Celsius or higher on any two of the first 10 days postpartum, excluding the first 24 hours. Persistent or higher fever beyond the first day warrants evaluation for infection.
- A nurse is reinforcing perineal hygiene teaching with a postpartum woman. Which instruction best prevents wound contamination and infection?
- Wipe and use the peri-bottle from front to back
- Use a shared washcloth to clean the perineum twice daily
- Insert a tampon to absorb lochia overnight
- Wipe from back to front to protect the urethra
Correct answer: Wipe and use the peri-bottle from front to back
Cleansing and wiping from front to back is the key instruction because it directs bacteria away from the urethra and healing perineal tissue toward the anus, reducing the risk of urinary tract and wound infection. Using a peri-bottle of warm water after voiding and patting dry are recommended. Tampons are contraindicated in the early postpartum period because they introduce infection risk into a healing reproductive tract.
- A nurse is preparing a postpartum woman for discharge and teaches her the AWHONN POST-BIRTH warning signs. Which symptom should prompt the woman to call 911 immediately?
- Cream-colored vaginal discharge in week two
- Mild perineal soreness when sitting
- Breasts that feel full before a feeding
- Chest pain or difficulty breathing
Correct answer: Chest pain or difficulty breathing
Chest pain or trouble breathing is a POST-BIRTH warning sign that warrants calling 911 immediately because it may indicate a pulmonary embolism or cardiac event, leading causes of maternal mortality. The AWHONN POST-BIRTH program teaches women to call 911 for chest pain, obstructed breathing, or seizures, and to call the provider for signs such as heavy bleeding, severe headache, or fever. Mild perineal soreness, normal breast fullness, and lochia alba are expected findings.
- During discharge teaching, a nurse instructs a postpartum woman about bleeding that requires prompt provider notification. Which description represents abnormal bleeding she should report?
- Lochia that increases briefly during breastfeeding
- A small gush of lochia when first standing up after lying down
- Saturating one perineal pad or more in an hour or passing a clot larger than an egg
- Lochia that turns pinkish-brown by the fourth day
Correct answer: Saturating one perineal pad or more in an hour or passing a clot larger than an egg
Saturating a pad in an hour or passing a clot larger than an egg is the description of abnormal, reportable bleeding and is a POST-BIRTH warning sign for hemorrhage. The other findings are normal: lochia pools while lying down and may gush on standing, breastfeeding stimulates oxytocin that briefly increases flow, and the progression to serosa by day four is expected. Distinguishing normal from excessive bleeding is essential postpartum education.
- A nurse is differentiating postpartum blues from postpartum depression for a new mother. Which statement accurately describes postpartum blues?
- A condition that only affects women with a prior psychiatric history
- Hallucinations and thoughts of harming the infant requiring emergency care
- Mild, transient mood swings and tearfulness that peak around days 4 to 5 and resolve within 2 weeks
- Persistent sadness and inability to care for the infant lasting more than a month
Correct answer: Mild, transient mood swings and tearfulness that peak around days 4 to 5 and resolve within 2 weeks
Postpartum blues are mild, self-limited mood swings, tearfulness, and emotional lability that typically peak around days 4 to 5 and resolve within about 2 weeks without treatment. They affect a majority of new mothers and are linked to hormonal shifts, fatigue, and adjustment. Symptoms lasting beyond 2 weeks or interfering with infant care suggest postpartum depression, and psychosis with hallucinations is a separate psychiatric emergency.
- A nurse is screening postpartum women for depression. Which standardized tool is most commonly used for this purpose?
- The Bishop score
- The Glasgow Coma Scale
- The APGAR score
- The Edinburgh Postnatal Depression Scale
Correct answer: The Edinburgh Postnatal Depression Scale
The Edinburgh Postnatal Depression Scale (EPDS) is the most widely used validated screening tool for perinatal and postpartum depression. It is a brief self-report questionnaire that helps identify women who need further evaluation, and a positive screen warrants referral for assessment and treatment. The Glasgow Coma Scale measures neurologic status, the Bishop score assesses cervical readiness for labor induction, and the Apgar score evaluates newborn transition.
- A nurse is caring for a woman on the first day after a cesarean birth. Which intervention best promotes recovery and prevents complications?
- Withhold all oral intake until the third postoperative day
- Encourage early ambulation, incentive spirometry, and splinting the incision when coughing
- Maintain strict bed rest for 48 hours to protect the incision
- Keep the abdominal dressing in place undisturbed for a week
Correct answer: Encourage early ambulation, incentive spirometry, and splinting the incision when coughing
Early ambulation, incentive spirometry, and incisional splinting during coughing best promote cesarean recovery. Ambulation reduces the risk of venous thromboembolism and ileus, deep breathing and spirometry prevent atelectasis and pneumonia, and splinting supports the incision and improves coughing effectiveness. Prolonged bed rest increases thromboembolism risk, and prolonged NPO status is unnecessary because early feeding is encouraged when bowel function returns.
- A nurse assesses a woman 24 hours after a cesarean birth and notes calf pain, unilateral leg swelling, and warmth. What is the priority nursing action?
- Vigorously massage the calf to relieve the cramp
- Apply a warm compress and have the woman walk it off
- Document the finding as expected postoperative edema
- Notify the provider and avoid massaging the leg
Correct answer: Notify the provider and avoid massaging the leg
Notifying the provider and avoiding massage is the priority because unilateral calf pain, swelling, and warmth suggest deep vein thrombosis, and the postpartum and post-cesarean states are hypercoagulable, raising the risk. Massaging the leg could dislodge a clot and cause a pulmonary embolism. The nurse should keep the woman at rest, avoid manipulating the leg, and prepare for diagnostic evaluation such as venous ultrasound.
- A nurse is teaching a postpartum woman measures to prevent venous thromboembolism. Which instruction is most appropriate?
- Remain in bed and keep the legs crossed when sitting
- Wrap the legs tightly with elastic bandages from toes to thigh
- Ambulate early and frequently and stay well hydrated
- Limit fluids to reduce swelling in the legs
Correct answer: Ambulate early and frequently and stay well hydrated
Early, frequent ambulation combined with adequate hydration is the most appropriate teaching to prevent venous thromboembolism. Movement promotes venous return and counters the hypercoagulable state of the postpartum period, while hydration prevents the hemoconcentration that increases clotting risk. Crossing the legs and prolonged immobility impede venous flow, and improperly applied tight wrapping can act as a tourniquet rather than provide graduated compression.
- A nurse is reviewing return of menstruation and ovulation with a breastfeeding mother who wants to avoid another pregnancy soon. What is the most accurate teaching?
- Breastfeeding fully prevents pregnancy for the first year
- Menstruation always resumes before ovulation, providing a warning
- Ovulation cannot occur until breastfeeding is completely stopped
- Ovulation can occur before the first menstrual period returns, so contraception is needed if pregnancy is not desired
Correct answer: Ovulation can occur before the first menstrual period returns, so contraception is needed if pregnancy is not desired
The accurate teaching is that ovulation can occur before the first postpartum menses, so a woman who wants to avoid pregnancy needs contraception even while amenorrheic. Although exclusive breastfeeding can suppress ovulation, it is not a reliable contraceptive unless the strict criteria of the lactational amenorrhea method are met, and protection diminishes as feeding patterns change. Counseling on contraceptive options before discharge is part of postpartum education.
- A nurse is counseling a postpartum couple about resuming sexual activity. Which education point is most accurate?
- Intercourse can usually resume once bleeding has stopped and the perineum has healed, often around the postpartum visit, and water-based lubricant may help with dryness
- Sexual activity must be avoided for a full 12 weeks regardless of healing
- Breastfeeding has no effect on vaginal lubrication
- Vaginal dryness is abnormal and indicates infection
Correct answer: Intercourse can usually resume once bleeding has stopped and the perineum has healed, often around the postpartum visit, and water-based lubricant may help with dryness
The accurate point is that intercourse can typically resume once lochia has stopped and perineal tissues have healed, commonly addressed around the postpartum visit, and water-based lubricant can ease dryness. Lactation lowers estrogen, which reduces vaginal lubrication and can cause dryness and dyspareunia that lubricant helps relieve. Contraception should also be discussed, since ovulation can precede the first menses.
- A nurse palpates a postpartum fundus that is higher than expected and boggy, and the woman continues to pass clots on the third postpartum day. The provider diagnoses subinvolution. What is the most common cause of subinvolution of the uterus?
- Adequate emptying of the bladder
- Retained placental fragments or infection
- Excessive ambulation after birth
- Early initiation of breastfeeding
Correct answer: Retained placental fragments or infection
Retained placental fragments and infection (endometritis) are the most common causes of subinvolution, in which the uterus fails to return to its prepregnant size at the normal pace. Retained tissue prevents the placental site from closing and keeps the uterus boggy and enlarged, leading to prolonged or recurrent red lochia and clots. Breastfeeding and ambulation actually promote involution, and an empty bladder supports uterine contraction.
- A nurse is teaching breast self-care to a breastfeeding mother to prevent nipple trauma and mastitis. Which instruction is appropriate?
- Limit each feeding to 5 minutes per breast to toughen the nipples
- Break suction with a clean finger before removing the infant from the breast and allow nipples to air dry
- Keep moist nursing pads against the nipples between feedings
- Wash the nipples with antibacterial soap before each feeding
Correct answer: Break suction with a clean finger before removing the infant from the breast and allow nipples to air dry
Breaking suction with a finger before removing the infant and allowing the nipples to air dry are appropriate measures to protect the nipples and reduce infection risk. Pulling the infant off an active latch traumatizes the nipple, and keeping nipples dry discourages the moist environment that promotes cracking and bacterial growth. Soap removes protective oils and dries the skin, and time-limiting feedings does not toughen nipples and can reduce milk transfer.
- A nurse is assessing a woman's emotional adaptation to motherhood. According to Rubin's framework, which behavior characterizes the taking-in phase during the first day or two postpartum?
- The mother is dependent, focused on her own needs, and recounts the birth experience
- The mother independently assumes full newborn care and resumes household tasks
- The mother shows disinterest in the infant and rejects help
- The mother delegates all infant care to family members long term
Correct answer: The mother is dependent, focused on her own needs, and recounts the birth experience
The taking-in phase is characterized by dependency, a focus on the mother's own physical needs (food, rest), and a desire to talk about and process the birth experience, typically during the first day or two. It is followed by the taking-hold phase, when she becomes more independent and eager to learn infant care, making it an ideal time for teaching. Disinterest or rejection of the infant is not a normal phase and warrants further assessment.
- A nurse is teaching a postpartum mother about promoting bonding and attachment with her newborn. Which behavior demonstrates positive attachment?
- Referring to the infant only as the baby and declining to hold the infant
- Avoiding eye contact and asking the nurse to keep the baby in the nursery
- Expressing disappointment in the infant's appearance repeatedly
- Making eye contact, using the en face position, and calling the infant by name
Correct answer: Making eye contact, using the en face position, and calling the infant by name
Making eye contact, holding the infant in the en face (face-to-face) position, and using the infant's name demonstrate positive attachment behaviors. These actions reflect engagement and developing emotional connection. Persistent avoidance of eye contact, reluctance to hold the infant, impersonal references, and repeated negative comments are warning signs of impaired bonding that warrant further assessment and support.
- A nurse is teaching a postpartum woman about preventing constipation, which is common after birth. Which combination of measures is most appropriate?
- Increase fluids and dietary fiber, ambulate, and use a stool softener as ordered
- Avoid all physical activity until the first bowel movement
- Routinely use stimulant enemas every morning
- Restrict fluids and fiber to rest the bowel
Correct answer: Increase fluids and dietary fiber, ambulate, and use a stool softener as ordered
Increasing fluids and fiber, ambulating, and using an ordered stool softener best address postpartum constipation. After birth, decreased intestinal motility, perineal pain, fear of straining a repair, and iron supplements all contribute to constipation, and these measures restore normal bowel function gently. Routine enemas and prolonged inactivity are not first-line, and restricting fluids and fiber would worsen the problem.
- A woman with a fourth-degree perineal laceration is being discharged. Which education is most important to protect the repair?
- Sit in a hot bath several times daily during the first day
- Avoid suppositories, enemas, and rectal manipulation, and use stool softeners to prevent straining
- Perform daily rectal digital exams to check healing
- Use scented sprays on the perineum to reduce odor
Correct answer: Avoid suppositories, enemas, and rectal manipulation, and use stool softeners to prevent straining
Avoiding rectal interventions such as suppositories and enemas, while using stool softeners to prevent straining, is the most important teaching for a fourth-degree laceration, which extends through the anal sphincter and rectal mucosa. Rectal manipulation can disrupt the repair, and a soft, easily passed stool protects the healing sphincter. Warm sitz baths help comfort later, but hot baths on the first day and scented products are not recommended.
- A nurse is teaching Kegel (pelvic floor) exercises to a postpartum woman. What is the primary benefit of these exercises?
- Increasing breast milk production
- Speeding the return of the uterus to its prepregnant size
- Strengthening the pelvic floor muscles to improve tone and reduce urinary incontinence
- Preventing deep vein thrombosis in the legs
Correct answer: Strengthening the pelvic floor muscles to improve tone and reduce urinary incontinence
The primary benefit of Kegel exercises is strengthening the pelvic floor muscles, which improves muscle tone, supports the pelvic organs, and reduces stress urinary incontinence common after childbirth. They involve contracting and relaxing the muscles used to stop the flow of urine. They do not affect uterine involution, milk supply, or thromboembolism risk, which are addressed by other interventions.
- A nurse is teaching a postpartum woman about the expected weight loss after birth. Approximately how much weight is typically lost immediately from the birth of the infant, placenta, and amniotic fluid?
- About 0.5 to 1 kilogram (1 to 2 pounds)
- About 15 to 18 kilograms (33 to 40 pounds)
- About 9 to 11 kilograms (20 to 24 pounds)
- About 4.5 to 5.8 kilograms (10 to 13 pounds)
Correct answer: About 4.5 to 5.8 kilograms (10 to 13 pounds)
An immediate loss of roughly 4.5 to 5.8 kilograms (10 to 13 pounds) is expected from delivery of the infant, placenta, and amniotic fluid. Additional weight is lost over the following weeks through diuresis and involution as the excess fluid and uterine tissue resolve. Counseling about gradual, realistic weight return supports healthy expectations, especially for breastfeeding mothers who have increased caloric needs.
- A nurse is reviewing nutrition with a breastfeeding mother. Which guidance is most accurate regarding her caloric and fluid needs?
- She should reduce caloric intake below prepregnancy levels to lose weight quickly
- She should restrict fluids to prevent fluid overload
- She needs additional calories and adequate fluids to support milk production
- She no longer needs prenatal vitamins or iron under any circumstances
Correct answer: She needs additional calories and adequate fluids to support milk production
A breastfeeding mother needs additional calories beyond her prepregnancy intake and adequate fluids to support milk production. Lactation increases energy and hydration requirements, and many providers recommend continuing a prenatal vitamin while nursing. Severe caloric or fluid restriction can compromise milk supply and maternal recovery, so rapid weight loss through restriction is discouraged during lactation.
- A postpartum woman is receiving magnesium sulfate for severe preeclampsia that persists after birth. The nurse assesses for magnesium toxicity. Which finding is the earliest sign of toxicity?
- Hyperactive reflexes and clonus
- Increased urine output
- A rising respiratory rate
- Loss of deep tendon reflexes
Correct answer: Loss of deep tendon reflexes
Loss of deep tendon reflexes is the earliest reliable sign of magnesium toxicity and precedes more dangerous effects. As serum magnesium rises, reflexes diminish and disappear first, followed by respiratory depression and ultimately cardiac compromise. The nurse monitors reflexes, respirations (at least 12 per minute), and urine output (at least 30 mL per hour), keeps calcium gluconate available as the antidote, and stops the infusion if toxicity is suspected.
- A nurse is monitoring a woman receiving postpartum magnesium sulfate for severe preeclampsia. Which parameter, if present, should prompt the nurse to stop the infusion and notify the provider?
- A blood pressure of 150/95 mmHg
- A urine output of 50 mL per hour
- Deep tendon reflexes that are present and normal
- A respiratory rate of 10 breaths per minute
Correct answer: A respiratory rate of 10 breaths per minute
A respiratory rate of 10 breaths per minute should prompt the nurse to stop the magnesium infusion and notify the provider because respiratory depression signals magnesium toxicity. Safe administration requires respirations of at least 12 per minute, urine output of at least 30 mL per hour, and present deep tendon reflexes. Calcium gluconate is the antidote and should be readily available. The elevated blood pressure reflects the underlying preeclampsia, not toxicity.
- A nurse provides discharge teaching to a woman who had gestational hypertension. Which instruction reflects current understanding of postpartum blood pressure risk?
- Antihypertensive medication is never needed after birth
- Blood pressure concerns end once the placenta is delivered
- Headaches after discharge are always normal and need no evaluation
- Continue monitoring blood pressure after discharge because hypertension and preeclampsia can develop or worsen in the postpartum period
Correct answer: Continue monitoring blood pressure after discharge because hypertension and preeclampsia can develop or worsen in the postpartum period
Continued blood pressure monitoring after discharge is the correct teaching because hypertensive disorders, including preeclampsia, can newly develop or worsen during the postpartum period, sometimes days after birth. Women should report severe or persistent headache, visual changes, or right upper quadrant pain, which are warning signs, and some require antihypertensive therapy after discharge. The risk does not end with delivery of the placenta.
- A nurse is assessing a postpartum woman who had a third-stage blood loss requiring close monitoring. The hematocrit is now lower than admission, and the woman reports fatigue and dizziness when standing. What is the most appropriate nursing action?
- Assist with position changes slowly and assess for orthostatic hypotension and ongoing bleeding
- Encourage her to ambulate independently to rebuild strength quickly
- Reassure her that dizziness is always expected and requires no monitoring
- Restrict her fluids to concentrate the blood
Correct answer: Assist with position changes slowly and assess for orthostatic hypotension and ongoing bleeding
Assisting with slow position changes while assessing for orthostatic hypotension and ongoing bleeding is most appropriate when a woman with reduced hematocrit reports dizziness on standing. Anemia from blood loss reduces oxygen-carrying capacity and predisposes to orthostatic hypotension, increasing fall risk. The nurse should change positions gradually, evaluate vital signs and lochia, and ensure safety, while encouraging iron-rich nutrition and prescribed supplementation.
- A nurse is teaching a postpartum woman how to assess her own fundus at home if instructed to monitor for firmness. Which instruction is correct?
- Massage continuously every 15 minutes around the clock regardless of firmness
- Push down firmly with both hands to express clots whenever convenient
- Avoid touching the abdomen entirely until the postpartum visit
- Empty the bladder first, then locate the firm fundus and gently massage if it feels soft
Correct answer: Empty the bladder first, then locate the firm fundus and gently massage if it feels soft
Emptying the bladder first and then locating the firm fundus, massaging gently only if it feels soft or boggy, is the correct instruction. A full bladder displaces the uterus and impairs tone, so voiding comes first, and massage is reserved for a soft fundus to stimulate contraction. Continuous unnecessary massage can fatigue the uterine muscle and worsen relaxation, so it is done only when needed.
- A nurse is reviewing a postpartum woman's labs and notes a white blood cell count of 18,000 per microliter on the first day after birth. The woman is afebrile with no signs of infection. How should the nurse interpret this value?
- It reflects severe dehydration requiring a fluid bolus
- It is a definitive sign of postpartum infection requiring antibiotics
- It indicates a hematologic malignancy
- It is an expected physiologic leukocytosis after birth
Correct answer: It is an expected physiologic leukocytosis after birth
A white blood cell count in this range is an expected physiologic leukocytosis after birth, reflecting the stress of labor and delivery, and can rise to roughly 25,000 to 30,000 per microliter without indicating infection. The nurse interprets lab values in the context of clinical findings; in an afebrile woman with no localizing signs, the elevation alone is normal. A rising count accompanied by fever or other symptoms would suggest infection.
- A nurse is teaching a postpartum woman the difference between normal lochia odor and a finding that should be reported. Which description should prompt the woman to notify her provider?
- A foul or fishy odor to the lochia
- A fleshy or earthy odor similar to menstrual flow
- A faint odor that lessens as lochia changes to alba
- No noticeable odor when lochia is light
Correct answer: A foul or fishy odor to the lochia
A foul or fishy odor to the lochia should be reported because it suggests endometritis or another uterine infection. Normal lochia has a fleshy, earthy odor similar to menstrual blood that should not be offensive. A foul smell, often combined with fever, uterine tenderness, or abnormal bleeding, indicates infection and warrants evaluation and likely antibiotic treatment.
- A nurse cares for a postpartum woman 2 days after birth who is hesitant to void due to perineal pain and has a palpable bladder. Which intervention should the nurse try first to promote voiding?
- Restrict her oral fluids until the urge returns
- Insert an indwelling catheter immediately
- Apply firm pressure over the bladder to express urine
- Run warm water over the perineum, provide privacy, and assist her to the bathroom
Correct answer: Run warm water over the perineum, provide privacy, and assist her to the bathroom
Non-invasive measures such as running warm water over the perineum, ensuring privacy, and assisting her to a normal voiding position should be tried first to stimulate voiding. Perineal trauma and edema can blunt the urge to void, and warmth, privacy, and ambulation often relax the urethra and promote urination without instrumentation. Catheterization is reserved for when these measures fail, since it carries infection risk, and external bladder pressure is not appropriate.
- A nurse is providing immunization teaching to a postpartum woman whose Tdap status during this pregnancy is unknown or who did not receive it. What is the recommendation?
- Wait until the 6-week visit because Tdap is contraindicated while breastfeeding
- Give Tdap only if the newborn is premature
- Administer Tdap during the postpartum stay to protect the newborn through cocooning
- Avoid Tdap because it interferes with rubella immunity
Correct answer: Administer Tdap during the postpartum stay to protect the newborn through cocooning
Administering Tdap during the postpartum hospital stay is recommended if the woman did not receive it during pregnancy, to reduce her risk of pertussis and protect the vulnerable newborn through cocooning of close contacts. Tdap is safe during breastfeeding, so lactation is not a reason to delay it. It can be co-administered with other postpartum vaccines such as MMR when indicated.
- A first-time mother who delivered 6 hours ago worries that the only fluid coming from her breast is a small amount of thick yellowish substance rather than milk. Which statement by the nurse best explains the benefit of this fluid to the newborn?
- The yellowish color indicates an infection in the breast and breastfeeding should be paused
- The yellowish fluid is colostrum, which is rich in secretory IgA antibodies and protein and helps protect the newborn's gut from infection
- The yellowish fluid is a sign of inadequate milk and the infant should be supplemented with formula until milk comes in
- The fluid has little nutritional value and serves only to keep the nipple moist
Correct answer: The yellowish fluid is colostrum, which is rich in secretory IgA antibodies and protein and helps protect the newborn's gut from infection
The thick yellowish fluid is colostrum, the immune-rich first milk that is high in secretory IgA, protein, and protective leukocytes. Secretory IgA coats the newborn's immature gastrointestinal and respiratory mucosa and blocks pathogens from attaching, providing passive immunity before the infant's own immune system matures. Colostrum is produced in small but appropriate amounts because the newborn's stomach is tiny, so the small volume is sufficient and not a sign of failure or infection.
- A nurse explains to a postpartum mother why early, frequent colostrum feedings are valuable even though the volume is small. Beyond immune protection, which additional benefit of colostrum should the nurse describe?
- It permanently sterilizes the newborn's intestinal tract
- It raises the newborn's blood glucose more than mature milk does
- It provides the entire fluid requirement so no further feeding is needed for 48 hours
- Its laxative effect helps the newborn pass meconium and lowers bilirubin levels
Correct answer: Its laxative effect helps the newborn pass meconium and lowers bilirubin levels
Colostrum has a natural laxative effect that promotes passage of meconium, which helps clear bilirubin from the gut and reduces the risk and severity of newborn jaundice. It also seeds the gut with protective factors and growth factors that mature the intestinal lining. Colostrum does not sterilize the bowel, is lower in lactose than mature milk, and does not eliminate the need for continued frequent feeding.
- A nurse assesses a breastfeeding dyad and wants to confirm an effective latch using objective signs of milk transfer rather than positioning alone. Which finding best indicates the infant is actively transferring milk?
- The infant falling asleep within 30 seconds of latching with no jaw movement
- A rhythmic suck-swallow pattern with audible swallowing after letdown
- A clicking sound with each suck and frequent slipping off the breast
- Rapid fluttering sucks with the cheeks drawn sharply inward
Correct answer: A rhythmic suck-swallow pattern with audible swallowing after letdown
A rhythmic suck-swallow rhythm with audible swallowing once letdown occurs is the strongest sign that milk is actually being transferred. Effective feeding shows slow, deep, drawing sucks with pauses and clear swallows. Rapid fluttery sucks with dimpled cheeks, clicking, or repeated slipping off suggest a shallow or broken latch that should be corrected, and immediate sleep without jaw movement signals the infant is not feeding effectively.
- A nurse is teaching a new mother the steps to achieve a deep latch when bringing the infant to the breast. Which instruction reflects correct technique?
- Push the infant's head firmly onto the breast as soon as the mouth begins to open slightly
- Wait for the infant to open wide, then bring the infant quickly to the breast aiming the nipple toward the roof of the mouth
- Keep the infant's body turned away from the mother so the head can rotate to the breast
- Place only the tip of the nipple between the infant's lips and hold it there
Correct answer: Wait for the infant to open wide, then bring the infant quickly to the breast aiming the nipple toward the roof of the mouth
Waiting for a wide gape and then bringing the infant swiftly to the breast with the nipple aimed toward the roof of the mouth promotes an asymmetric, deep latch that captures more of the lower areola. The infant should be turned tummy-to-tummy with the head and body aligned, not twisted. Pushing on the back of the head, latching on a closed or barely open mouth, or offering only the nipple tip produces a shallow, painful latch with poor milk transfer.
- A nurse measures fundal height on a postpartum woman and wants to document it accurately relative to the umbilicus. Which technique correctly describes how to assess fundal height postpartum?
- Measure fundal height with a tape measure from the symphysis as is done during pregnancy
- Press deeply with both hands into the abdomen without supporting the lower segment to find the fundus quickly
- Have the woman stand so gravity lowers the fundus before measuring
- Support the lower uterus with one hand at the symphysis while palpating the fundus with the other, then note its level in fingerbreadths above or below the umbilicus
Correct answer: Support the lower uterus with one hand at the symphysis while palpating the fundus with the other, then note its level in fingerbreadths above or below the umbilicus
Correct technique is to stabilize the lower uterine segment with one hand placed just above the symphysis pubis while the other hand palpates the fundus, then describe its position in fingerbreadths (or centimeters) above or below the umbilicus. Supporting the lower segment prevents downward displacement or uterine inversion during palpation. The woman should be supine with knees slightly flexed and her bladder emptied first, since a full bladder elevates and displaces the fundus.
- A nurse performs fundal massage on a woman with a boggy uterus. Which technique protects the uterus from inversion while stimulating contraction?
- Massage the fundus continuously for several minutes after it has become firm
- Apply vigorous downward pressure on the fundus with both hands until clots express
- Cup one hand over the fundus and support the lower uterine segment with the other hand just above the symphysis while massaging in a circular motion
- Pull upward on the fundus to lift the uterus out of the pelvis
Correct answer: Cup one hand over the fundus and support the lower uterine segment with the other hand just above the symphysis while massaging in a circular motion
Cupping one hand over the fundus while the other hand braces the lower uterine segment just above the symphysis allows safe circular massage that stimulates contraction without risking uterine inversion. Once the fundus firms, massage should stop, because continued massage can fatigue and overstimulate the muscle, leading to relaxation. Aggressive downward pressure or upward traction on a relaxed uterus can cause inversion, a life-threatening emergency.
- A nurse is documenting lochia volume on a postpartum woman who has saturated about a 4-inch stain on her perineal pad over one hour. Using a standard pad-saturation scale, how should the nurse describe this amount of lochia?
- Scant lochia
- Moderate lochia
- Heavy lochia
- Light lochia
Correct answer: Moderate lochia
A stain roughly 4 inches (about 10 cm) on the pad within one hour is described as moderate lochia on the common saturation scale. Scant is a stain less than about 1 inch, light is less than about 4 inches, moderate is less than about 6 inches, and heavy is a fully saturated pad within one hour. Standardized terms make documentation consistent, and weighing pads (1 gram equals about 1 mL) gives a more precise quantitative measure when bleeding is a concern.
- While assessing lochia, the nurse notes the woman has been lying supine for two hours and a large gush of dark blood and small clots passes when she first stands. The fundus is firm and bleeding then slows to a moderate flow. How should the nurse interpret this finding?
- This indicates uterine atony requiring immediate uterotonics
- This is expected pooling of lochia that drained on position change, not hemorrhage
- This is a sign of a cervical laceration requiring surgical repair
- This confirms retained placental fragments requiring evacuation
Correct answer: This is expected pooling of lochia that drained on position change, not hemorrhage
A gush of pooled lochia with small clots on standing after lying down, when the fundus is firm and flow then returns to moderate, is an expected finding caused by blood collecting in the vagina that drains with gravity. The firm fundus rules out atony as the source. Continuous heavy bright-red bleeding with a firm fundus would instead suggest a laceration, and a persistently boggy uterus would suggest atony, but neither matches this picture.
- A breastfeeding woman on postpartum day 5 reports a hard, red, wedge-shaped, tender area on one breast with a temperature of 38.6 degrees Celsius (101.5 degrees Fahrenheit), body aches, and fatigue. Which set of interventions is most appropriate for this lactational mastitis?
- Apply deep, vigorous massage to the firm area to break up the blockage
- Continue breastfeeding or expressing milk from the affected breast, apply cold compresses between feedings, use anti-inflammatory analgesics, and notify the provider for possible antibiotics
- Pump the affected breast to complete emptiness every hour around the clock
- Stop breastfeeding immediately and apply tight binding to the affected breast
Correct answer: Continue breastfeeding or expressing milk from the affected breast, apply cold compresses between feedings, use anti-inflammatory analgesics, and notify the provider for possible antibiotics
Continuing to feed or express from the affected breast, applying cold compresses between feeds, taking anti-inflammatory analgesics, and contacting the provider for possible antibiotics is the current evidence-based management of mastitis. Keeping milk moving prevents stasis, and first-line antibiotics such as dicloxacillin or cephalexin are compatible with continued breastfeeding. Updated guidance specifically advises against aggressive deep massage, which can worsen inflammation, and against weaning or overpumping, which causes stasis or overstimulation.
- A nurse teaches a mother how to reduce her risk of recurrent mastitis. Which instruction is most appropriate?
- Feed or express regularly to avoid prolonged milk stasis, ensure a good latch, and avoid tight bras or pressure on the breast
- Wean from the affected breast permanently after one episode of mastitis
- Limit the number of feedings to let the breast rest fully between sessions
- Routinely apply firm pressure with the thumb during feedings to keep ducts open
Correct answer: Feed or express regularly to avoid prolonged milk stasis, ensure a good latch, and avoid tight bras or pressure on the breast
Avoiding milk stasis through regular feeding or expression, ensuring an effective latch, and avoiding constriction from tight bras or external pressure best prevent recurrent mastitis. Stasis and incomplete drainage allow inflammation and bacterial overgrowth. Restricting feedings promotes stasis, firm thumb pressure can traumatize tissue, and weaning is not necessary because continued breastfeeding is safe and part of treatment.
- A nurse obtains routine vital signs on a woman on the second postpartum day. Which set of values should the nurse recognize as a warning sign requiring prompt evaluation rather than a normal postpartum adaptation?
- Respiratory rate 16 with oxygen saturation 98 percent
- Heart rate 60 with blood pressure 118/72
- Temperature 37.6 degrees Celsius with mild fatigue
- Temperature 38.4 degrees Celsius, heart rate 112, and uterine tenderness
Correct answer: Temperature 38.4 degrees Celsius, heart rate 112, and uterine tenderness
A temperature of 38.4 degrees Celsius after the first 24 hours combined with tachycardia of 112 and uterine tenderness is a warning sign that suggests infection such as endometritis and requires evaluation. Postpartum fever is defined as 38.0 degrees Celsius or higher on any two of the first ten days, excluding the first 24 hours. A heart rate of 60 reflects normal postpartum bradycardia, and the other findings are within normal limits.
- A nurse is establishing the frequency of postpartum vital sign assessment for a woman who delivered vaginally without complications. Which schedule reflects standard immediate postpartum monitoring during the fourth stage of labor?
- Only when the woman reports symptoms
- Every 15 minutes for the first hour, then every 30 minutes for the next hour, then per protocol as the woman stabilizes
- Every 4 hours throughout the first 24 hours regardless of stability
- Once on admission to the postpartum unit and then once per shift
Correct answer: Every 15 minutes for the first hour, then every 30 minutes for the next hour, then per protocol as the woman stabilizes
During the fourth stage (the first 1 to 2 hours after birth) vital signs and fundal and lochia checks are typically performed every 15 minutes for the first hour, then every 30 minutes during the second hour, with frequency decreasing as the woman remains stable. This close monitoring catches early hemorrhage and hemodynamic instability when the risk is highest. Less frequent checks in this critical window could delay recognition of deterioration.
- A nurse reviews the chart of an Rh-negative woman to determine whether postpartum Rho(D) immune globulin is indicated. Which newborn finding makes the postpartum dose necessary?
- The newborn's blood type is Rh-negative
- The newborn is blood type O regardless of Rh factor
- The newborn's blood type is Rh-positive
- The newborn has a positive direct Coombs test from a prior pregnancy antibody
Correct answer: The newborn's blood type is Rh-positive
Postpartum Rho(D) immune globulin is indicated when the newborn is Rh-positive and the mother is Rh-negative and unsensitized, because fetal-to-maternal hemorrhage at birth can expose the mother to Rh-positive cells and trigger antibody formation. If the newborn is Rh-negative, there is no Rh antigen to sensitize the mother and the dose is not needed. The ABO type alone does not determine the need for Rh immune globulin.
- A nurse caring for an Rh-negative woman after a difficult birth with suspected significant fetal-maternal hemorrhage anticipates that additional testing will guide the immune globulin dose. Which test quantifies the volume of fetal blood in the maternal circulation to determine whether more than one standard dose is required?
- The indirect Coombs test
- The glucose tolerance test
- The Kleihauer-Betke test
- The rubella titer
Correct answer: The Kleihauer-Betke test
The Kleihauer-Betke test measures the amount of fetal hemoglobin (and thus fetal blood volume) in the maternal circulation, allowing calculation of whether more than the standard 300 microgram dose of Rho(D) immune globulin is needed after a large fetal-maternal hemorrhage. One standard dose covers roughly 30 mL of fetal whole blood. The indirect Coombs detects maternal antibodies, while a rubella titer and glucose tolerance test are unrelated to Rh dosing.
- A breastfeeding woman on postpartum day 3 describes both breasts as overfull and tense, making the areola so firm the infant cannot grasp it. Which technique should the nurse teach to help the infant latch despite the engorgement?
- Apply firm continuous heat to the breasts for 30 minutes before each feeding
- Perform reverse pressure softening or hand-express a small amount of milk to soften the areola before latching
- Offer formula until the breasts soften so the infant does not have to work as hard
- Wait until the engorgement resolves on its own before attempting to feed
Correct answer: Perform reverse pressure softening or hand-express a small amount of milk to soften the areola before latching
Reverse pressure softening (gently pressing the areola inward toward the chest wall) or expressing a small amount of milk softens the areola so the infant can achieve a deep latch during engorgement. A soft, graspable areola lets the infant drain the breast, which is the key to relieving engorgement. Prolonged heat can increase swelling, waiting allows stasis to worsen, and routinely substituting formula reduces drainage and prolongs the engorgement.
- A nurse evaluates a postpartum woman with bilateral breast engorgement and reviews her use of cabbage leaf compresses. Which statement about this comfort measure is accurate?
- Cabbage leaves are an antibiotic treatment that cures mastitis
- Chilled cabbage leaves applied to the breasts may reduce engorgement discomfort but should be removed once relief occurs to avoid suppressing milk supply
- Cabbage leaves increase milk production and should be used to boost supply
- Cabbage leaves should be kept on continuously for several days to maximize the effect
Correct answer: Chilled cabbage leaves applied to the breasts may reduce engorgement discomfort but should be removed once relief occurs to avoid suppressing milk supply
Chilled cabbage leaves can ease the discomfort of engorgement, but they should be removed once relief is felt because prolonged or excessive use may reduce milk supply. For a mother who wants to continue breastfeeding, the goal is comfort while preserving supply, so they are used briefly. Cabbage leaves do not increase milk production and are not an antibiotic, so they do not treat mastitis.
- A nurse is caring for a woman 24 hours after a cesarean birth performed after prolonged labor and prolonged rupture of membranes. The nurse monitors closely for endometritis. Which finding is most characteristic of this infection?
- Isolated breast tenderness without fever
- Uterine tenderness with fever and foul-smelling lochia
- Scant lochia alba on postpartum day two
- A firm nontender fundus with odorless lochia serosa
Correct answer: Uterine tenderness with fever and foul-smelling lochia
Uterine (fundal) tenderness combined with fever of 38.0 degrees Celsius or higher and foul-smelling lochia is the classic triad of postpartum endometritis, typically appearing within the first several days. Cesarean birth after labor and prolonged rupture of membranes are major risk factors. A firm, nontender fundus with normal-smelling lochia or scant lochia alba reflects normal involution, and isolated breast tenderness points to a breast problem rather than uterine infection.
- A nurse reviews risk factors for postpartum endometritis to identify which patients need closer monitoring. Which patient is at highest risk for developing this infection?
- A woman who had an elective repeat cesarean before labor began with intact membranes
- A multiparous woman who delivered vaginally without instrumentation
- A woman with a spontaneous vaginal birth and intact perineum
- A woman who had a cesarean birth after prolonged rupture of membranes and multiple vaginal exams
Correct answer: A woman who had a cesarean birth after prolonged rupture of membranes and multiple vaginal exams
A cesarean birth performed after prolonged rupture of membranes with multiple vaginal examinations carries the highest risk for endometritis, because cesarean delivery is the single greatest risk factor and is compounded by ascending bacteria from ruptured membranes and repeated exams. An uncomplicated vaginal birth and an elective prelabor cesarean with intact membranes carry much lower risk. Identifying high-risk women guides surveillance and prophylactic antibiotic decisions.
- A nurse is providing postpartum teaching about thromboprophylaxis to a woman who had a cesarean birth and is obese with a prior history of deep vein thrombosis. The provider has prescribed low-molecular-weight heparin. Which teaching point is most appropriate?
- Report any unusual bruising, bleeding, or signs of leg pain and swelling while on the anticoagulant
- Anticoagulation eliminates the need to ambulate or wear compression devices
- The medication will be stopped as soon as she is discharged regardless of risk factors
- She should remain on bed rest while taking the medication to prevent bleeding
Correct answer: Report any unusual bruising, bleeding, or signs of leg pain and swelling while on the anticoagulant
Teaching the woman to report unusual bruising, bleeding, or new leg pain and swelling is most appropriate because low-molecular-weight heparin increases bleeding risk while she remains at high thromboembolism risk from cesarean birth, obesity, and prior clot. Anticoagulation complements rather than replaces early ambulation and compression devices, all of which reduce clot risk. The duration of prophylaxis is individualized to her risk factors and is not automatically stopped at discharge.
- A nurse identifies postpartum hemorrhage in a woman whose uterus remains boggy and bleeding continues despite fundal massage and an empty bladder. The provider orders a first-line uterotonic. Which medication is typically given first for atony-related hemorrhage?
- Carboprost in a woman with asthma
- Methylergonovine in a woman with hypertension
- Magnesium sulfate
- Oxytocin
Correct answer: Oxytocin
Oxytocin is the first-line uterotonic for postpartum hemorrhage from uterine atony because it directly stimulates uterine contraction and has few contraindications. Methylergonovine is avoided in women with hypertension or preeclampsia because it raises blood pressure, and carboprost (a prostaglandin) is avoided in women with asthma because it can cause bronchospasm. Magnesium sulfate is a uterine relaxant used for seizure prophylaxis, not a uterotonic, so it would worsen atony.
- A nurse assesses a woman with continued moderate to heavy bright-red vaginal bleeding immediately after birth, but the fundus is firm and well contracted at the umbilicus. What is the most likely source of this bleeding?
- Normal lochia rubra
- Retained placental fragments
- A genital tract laceration such as a cervical or vaginal tear
- Uterine atony
Correct answer: A genital tract laceration such as a cervical or vaginal tear
Steady bright-red bleeding with a firm, well-contracted fundus points to a genital tract laceration of the cervix or vagina rather than the uterus. A firm fundus rules out atony, and retained fragments typically produce a boggy uterus and later bleeding. Recognizing that bleeding from a firm uterus signals a laceration directs the team to inspect the birth canal and arrange surgical repair, since fundal massage will not stop bleeding from a tear.
- A nurse is reviewing the components of a postpartum assessment using the BUBBLE-HE framework. Which component does the H represent?
- Hematocrit only
- Hydration status only
- Homans sign and lower extremity assessment for thrombosis
- Hearing screening
Correct answer: Homans sign and lower extremity assessment for thrombosis
In the BUBBLE-HE postpartum assessment mnemonic, H stands for Homans sign and the related assessment of the lower extremities for signs of venous thrombosis (the E stands for emotional status and episiotomy/perineum). The full mnemonic covers Breasts, Uterus, Bladder, Bowel, Lochia, Episiotomy/perineum, Homans/lower extremities, and Emotional status. While routine Homans testing is no longer emphasized because it is unreliable, the framework reminds the nurse to assess the legs for redness, warmth, and swelling.
- A postpartum woman who had severe preeclampsia is being monitored after delivery. The nurse knows that magnesium sulfate is typically continued for what duration after birth for seizure prophylaxis in most protocols?
- About 24 hours postpartum
- Until the placenta is delivered, then stopped
- For 7 days postpartum
- Until the first menses returns
Correct answer: About 24 hours postpartum
Magnesium sulfate for seizure prophylaxis in preeclampsia or eclampsia is typically continued for about 24 hours after delivery, because the risk of seizures persists into the early postpartum period and does not end with delivery of the placenta. During this time the nurse monitors deep tendon reflexes, respirations of at least 12 per minute, and urine output of at least 30 mL per hour, with calcium gluconate available as the antidote.
- A nurse is teaching a postpartum woman who had an uncomplicated vaginal birth about resuming activity and exercise. Which guidance is most appropriate?
- Lift no objects heavier than the newborn for six months
- Begin with walking and gentle activity, gradually increasing as comfort and bleeding allow, and avoid heavy lifting and strenuous exercise until cleared
- Avoid all movement for two weeks to allow complete healing
- Resume high-intensity workouts on the first day to regain fitness quickly
Correct answer: Begin with walking and gentle activity, gradually increasing as comfort and bleeding allow, and avoid heavy lifting and strenuous exercise until cleared
Starting with walking and gentle activity and gradually increasing intensity as comfort and bleeding allow, while avoiding heavy lifting and strenuous exercise until cleared, is the most appropriate guidance after an uncomplicated vaginal birth. Early gentle movement promotes circulation and recovery and reduces thromboembolism risk. Resuming intense exercise immediately can increase bleeding, while prolonged complete immobility raises clot risk and is not recommended.
- A nurse provides nutrition counseling to a postpartum woman who had significant blood loss and a hemoglobin of 9 g/dL. Which dietary teaching best supports her recovery?
- Restrict iron intake to prevent constipation
- Rely solely on increased fluids to restore red blood cells
- Increase intake of iron-rich foods such as lean red meat, beans, and leafy greens and take prescribed iron with vitamin C to enhance absorption
- Avoid all protein to reduce the workload on the kidneys
Correct answer: Increase intake of iron-rich foods such as lean red meat, beans, and leafy greens and take prescribed iron with vitamin C to enhance absorption
Encouraging iron-rich foods such as lean red meat, beans, and leafy greens along with prescribed iron supplementation paired with vitamin C to boost absorption best supports recovery from postpartum anemia. Iron is needed to rebuild red blood cell mass after blood loss. Avoiding protein would impair tissue repair, restricting iron would worsen anemia, and fluids alone cannot replace the iron needed for hemoglobin synthesis. A stool softener can manage iron-related constipation.
- A nurse evaluates a postpartum woman's understanding of when to contact her provider about her incision after a cesarean birth. Which statement indicates correct understanding?
- I should expect heavy bleeding from the incision for the first week
- I will call if the incision becomes increasingly red, swollen, warm, or starts draining pus or separating
- A small amount of redness means the incision is healing and never needs reporting
- I will call only if the incision is completely painless
Correct answer: I will call if the incision becomes increasingly red, swollen, warm, or starts draining pus or separating
Recognizing that increasing redness, swelling, warmth, purulent drainage, or wound separation should be reported indicates correct understanding, because these are signs of a surgical site infection or dehiscence. Mild, decreasing discomfort and a thin line of healing are expected, but worsening signs warrant evaluation. An incision should not bleed heavily for a week, and dismissing all redness ignores the possibility of early infection.
- A nurse is caring for a woman with a known history of postpartum hemorrhage in a prior birth who has just delivered her second child. Recognizing her elevated risk, which proactive nursing measure is most appropriate in the immediate postpartum period?
- Withhold uterotonics unless bleeding becomes heavy
- Discontinue IV access promptly to encourage ambulation
- Limit fundal assessments to once per shift to avoid disturbing the woman
- Maintain IV access, continue oxytocin per protocol, and assess fundal tone and lochia more frequently
Correct answer: Maintain IV access, continue oxytocin per protocol, and assess fundal tone and lochia more frequently
For a woman with a prior postpartum hemorrhage, maintaining IV access, continuing prophylactic oxytocin per protocol, and assessing fundal tone and lochia more frequently are the most appropriate proactive measures, because a previous hemorrhage strongly predicts recurrence. Early recognition and active management of the third stage reduce blood loss. Removing IV access, withholding prophylaxis, or reducing assessment frequency would delay detection and treatment of recurrent bleeding.
- A nurse is assessing a postpartum woman who reports a severe, persistent headache unrelieved by acetaminophen, blurred vision, and a blood pressure of 158/104 mmHg on postpartum day 2. What is the nurse's priority action?
- Reassure her that headaches are an expected part of recovery and offer rest
- Document the findings and reassess at the next routine check in 8 hours
- Notify the provider promptly, as these are signs of postpartum preeclampsia requiring evaluation and possible treatment
- Encourage caffeine intake to relieve the headache
Correct answer: Notify the provider promptly, as these are signs of postpartum preeclampsia requiring evaluation and possible treatment
Promptly notifying the provider is the priority because a severe unrelenting headache, visual changes, and a blood pressure of 158/104 are warning signs of postpartum preeclampsia, which can develop or worsen days after birth and can progress to seizures or stroke. These symptoms require urgent evaluation and may need antihypertensive therapy and seizure prophylaxis. Dismissing the symptoms or delaying assessment could allow a dangerous escalation.
- A nurse is teaching a breastfeeding mother how to recognize and address a plugged milk duct before it progresses. Which self-care measure is most appropriate for a tender lump without fever?
- Bind the breast tightly to prevent further milk production
- Continue feeding or expressing, position the infant's chin toward the lump, and apply cold or brief warmth for comfort while avoiding aggressive massage
- Apply deep, forceful massage directly over the lump throughout each feeding
- Stop feeding from that breast until the lump disappears
Correct answer: Continue feeding or expressing, position the infant's chin toward the lump, and apply cold or brief warmth for comfort while avoiding aggressive massage
Continuing to feed or express, pointing the infant's chin toward the lump to help drain that area, and using gentle comfort measures while avoiding aggressive massage is the appropriate approach to a plugged duct without fever. Current guidance discourages forceful massage because it can worsen inflammation and edema. Stopping feeding or binding the breast promotes milk stasis, which makes the plug and any progression to mastitis more likely.
- A nurse is counseling a woman with gestational diabetes about her glucose status after birth. Which teaching point is accurate regarding the immediate postpartum period?
- Glucose monitoring is unnecessary once the baby is delivered
- Insulin needs usually drop sharply after delivery of the placenta, so glucose should be monitored to prevent hypoglycemia
- Insulin requirements rise sharply after birth and higher doses are needed
- Gestational diabetes always becomes permanent diabetes immediately after birth
Correct answer: Insulin needs usually drop sharply after delivery of the placenta, so glucose should be monitored to prevent hypoglycemia
Insulin needs usually fall sharply right after delivery of the placenta because the placental hormones that caused insulin resistance are gone, so glucose must be monitored to prevent hypoglycemia and insulin doses are reduced or stopped. Gestational diabetes often resolves postpartum, though it raises the lifetime risk of type 2 diabetes, prompting a follow-up glucose tolerance test at the postpartum visit. Stopping all monitoring immediately is not appropriate.
- A postpartum woman 36 hours after birth becomes acutely short of breath, anxious, and tachycardic with chest pain and a drop in oxygen saturation. What is the nurse's priority action?
- Encourage the woman to breathe into a paper bag for presumed anxiety
- Call for rapid response, apply oxygen, and prepare for evaluation of suspected pulmonary embolism
- Document the symptoms and reassess in one hour
- Have the woman ambulate in the hallway to improve her breathing
Correct answer: Call for rapid response, apply oxygen, and prepare for evaluation of suspected pulmonary embolism
Calling for rapid response, applying oxygen, and preparing for evaluation of a pulmonary embolism is the priority because sudden dyspnea, chest pain, tachycardia, and falling oxygen saturation in the hypercoagulable postpartum period are classic signs of a potentially fatal embolism. Pulmonary embolism is a leading cause of maternal death. Treating this as anxiety, encouraging ambulation, or delaying assessment could be life-threatening.
- A nurse is teaching a postpartum woman about expected changes in her hair and skin during the months after birth. Which statement is accurate?
- Increased hair shedding and fading of skin hyperpigmentation such as the linea nigra are normal and usually resolve over several months
- Hair shedding indicates a thyroid disorder in all cases
- Permanent hair loss is expected and will not regrow
- Skin darkening from pregnancy is permanent and irreversible
Correct answer: Increased hair shedding and fading of skin hyperpigmentation such as the linea nigra are normal and usually resolve over several months
Increased hair shedding (telogen effluvium) and gradual fading of pregnancy-related hyperpigmentation such as the linea nigra and chloasma are normal postpartum changes that typically resolve over several months as hormone levels return to baseline. The hair shedding reflects hairs that were retained during pregnancy now entering the resting phase, and it is usually self-limited rather than a sign of thyroid disease, although persistent or severe symptoms warrant evaluation.
- A nurse is teaching a new mother safe sleep and self-care strategies to cope with fatigue in the early weeks. Which recommendation best supports maternal rest while maintaining infant safety?
- Bring the infant into the adult bed under blankets so the mother can sleep more deeply
- Stay awake through the night to monitor the infant continuously
- Sleep when the baby sleeps and accept help with household tasks, while always placing the infant on its back in a separate safe sleep space
- Place the infant prone in the crib so it sleeps longer and the mother can rest
Correct answer: Sleep when the baby sleeps and accept help with household tasks, while always placing the infant on its back in a separate safe sleep space
Encouraging the mother to rest when the infant sleeps and to accept help, while keeping the infant on its back in a separate safe sleep space, best balances maternal rest with infant safety. Adequate rest supports recovery and mental health. Bed-sharing under blankets and prone positioning both increase the risk of sudden unexpected infant death, so they are unsafe ways to extend sleep.
- A nurse is reviewing the signs that distinguish postpartum depression from the normal baby blues during a follow-up call on postpartum day 14. Which finding most strongly indicates postpartum depression rather than baby blues and warrants referral?
- Fatigue that improves with rest and help from family
- Occasional tearfulness that resolved by the end of the first week
- Persistent sadness, hopelessness, and difficulty bonding with or caring for the infant lasting beyond two weeks
- Mild mood swings during the first few days that have since improved
Correct answer: Persistent sadness, hopelessness, and difficulty bonding with or caring for the infant lasting beyond two weeks
Persistent sadness, hopelessness, and trouble bonding with or caring for the infant that lasts beyond two weeks strongly indicates postpartum depression and warrants referral and treatment. Baby blues are mild, peak around days 4 to 5, and resolve within about two weeks without intervention. Because the symptoms here are persistent and impair functioning past that window, they exceed normal blues, and screening with a validated tool and prompt referral are indicated.
- A woman experiences brief, generalized shivering and feels chilled within the first hour after a vaginal birth. Her temperature is 37.2 degrees Celsius, vital signs are stable, and she has no other symptoms. How should the nurse interpret and respond to this finding?
- This is an early sign of infection requiring immediate antibiotics
- This indicates a transfusion-type reaction requiring the IV to be stopped
- This signals hypovolemic shock and the rapid response team should be activated
- This is a common, benign postpartum chill; provide a warm blanket and reassurance
Correct answer: This is a common, benign postpartum chill; provide a warm blanket and reassurance
A brief postpartum chill with shivering in the first hour, with a normal temperature and stable vital signs, is a common benign finding thought to result from vasomotor changes, fluid shifts, and the sudden internal-external temperature difference after birth. The appropriate response is a warm blanket and reassurance. Because there is no fever, hypotension, or other sign of infection, transfusion reaction, or shock, no emergency intervention is warranted, though a chill accompanied by fever later would prompt evaluation for infection.
- A term newborn at 1 minute of life has a heart rate of 90 beats per minute, slow irregular respirations with a weak cry, some flexion of the extremities, a grimace in response to suctioning, and a pink body with blue hands and feet. What is the correct Apgar score?
Correct answer: 5
The correct Apgar score is 5. Each of the five components is scored 0, 1, or 2: heart rate under 100 earns 1, slow or irregular respirations with a weak cry earns 1, some flexion earns 1, a grimace earns 1, and a body that is pink with blue extremities (acrocyanosis) earns 1, totaling 5. The maximum score is 10, and scores are assigned at 1 and 5 minutes; a heart rate over 100 would have raised the cardiac point to 2.
- A nurse is teaching a new graduate the five components evaluated in the Apgar score. Which list correctly names all five parameters?
- Respiratory rate, oxygen saturation, muscle tone, reflexes, and color
- Heart rate, respiratory effort, capillary refill, reflexes, and weight
- Heart rate, blood pressure, muscle tone, temperature, and color
- Heart rate, respiratory effort, muscle tone, reflex irritability, and color
Correct answer: Heart rate, respiratory effort, muscle tone, reflex irritability, and color
The five Apgar components are heart rate, respiratory effort, muscle tone, reflex irritability, and color. Each is scored 0 to 2 for a maximum of 10, assessed at 1 and 5 minutes of life. Blood pressure, oxygen saturation, temperature, capillary refill, and weight are not part of the Apgar score, even though several are part of a broader newborn assessment.
- A newborn's Apgar score is 4 at 5 minutes. According to standard newborn resuscitation guidance, what is the most appropriate nursing action?
- Continue resuscitation efforts and reassess the Apgar score every 5 minutes until 20 minutes or the score is at least 7
- Administer naloxone immediately
- Document the score and continue routine care
- Repeat the score only once at 10 minutes regardless of value
Correct answer: Continue resuscitation efforts and reassess the Apgar score every 5 minutes until 20 minutes or the score is at least 7
The correct action is to continue resuscitation and reassign the Apgar score every 5 minutes up to 20 minutes when the 5-minute score is below 7. The Apgar score reflects the infant's response and the effectiveness of resuscitation; it does not by itself dictate resuscitation, which is guided by heart rate and respirations. Naloxone is not recommended as part of initial neonatal resuscitation.
- A nurse performs a New Ballard Score on a newborn and obtains a total of 30 by adding the neuromuscular and physical maturity subscores. Approximately what gestational age does this total represent?
- About 44 weeks
- About 32 weeks
- About 36 weeks
- About 40 weeks
Correct answer: About 36 weeks
A New Ballard total of 30 corresponds to approximately 36 weeks of gestation. On the New Ballard maturity rating chart, each 5-point increment represents roughly two additional weeks, so a total of 20 equals about 32 weeks and 40 equals about 40 weeks. The scale spans -10 (about 20 weeks) to 50 (about 44 weeks) and combines six neuromuscular and six physical maturity criteria.
- Which set of criteria are the neuromuscular maturity components of the New Ballard Score?
- Heart rate, tone, color, reflexes, and respiratory effort
- Posture, square window, arm recoil, popliteal angle, scarf sign, and heel to ear
- Skin, lanugo, plantar surface, breast, eye and ear, and genitals
- Head circumference, length, weight, posture, and skin
Correct answer: Posture, square window, arm recoil, popliteal angle, scarf sign, and heel to ear
The neuromuscular maturity criteria of the New Ballard Score are posture, square window (wrist), arm recoil, popliteal angle, scarf sign, and heel to ear. The other six criteria (skin, lanugo, plantar surface, breast, eye and ear, and genitals) make up physical maturity. Together the two categories estimate gestational age independent of obstetric dating.
- A nurse is preparing to administer vitamin K to a healthy term newborn. What is the correct dose and route?
- 0.5 mg given orally
- 1 mg given subcutaneously
- 2 mg given intravenously
- 1 mg given intramuscularly
Correct answer: 1 mg given intramuscularly
The correct prophylaxis is a single 1 mg dose of vitamin K1 (phytonadione) given intramuscularly, typically into the vastus lateralis, for newborns weighing more than 1,500 grams. Intramuscular administration is preferred over oral because it more reliably prevents both classic and late vitamin K deficiency bleeding. Vitamin K is given because newborns have low vitamin K stores and sterile guts that cannot yet synthesize it.
- A nurse administers erythromycin 0.5% ophthalmic ointment to a newborn. What is the primary purpose of this treatment?
- To prevent gonococcal ophthalmia neonatorum
- To treat an existing chlamydial pneumonia
- To prevent retinopathy of prematurity
- To dilate the pupils for a retinal exam
Correct answer: To prevent gonococcal ophthalmia neonatorum
Erythromycin 0.5% ophthalmic ointment is given primarily to prevent gonococcal ophthalmia neonatorum, a sight-threatening eye infection acquired during passage through the birth canal. A single ribbon is applied to each lower conjunctival sac within the first hour or so after birth. It does not reliably prevent chlamydial conjunctivitis, and it has no role in retinopathy of prematurity or pupil dilation.
- A nurse plans to delay the newborn's erythromycin eye ointment by about an hour after birth. What is the rationale most consistent with current practice?
- The medication is only effective after the first feeding
- The ointment must be refrigerated before use
- Pupils must constrict before the ointment can be applied
- Delaying allows eye contact and bonding during the first period of reactivity without missing the prophylaxis window
Correct answer: Delaying allows eye contact and bonding during the first period of reactivity without missing the prophylaxis window
Brief delay of eye prophylaxis is acceptable to support parent-infant eye contact and bonding during the first period of reactivity, as long as it is given within the recommended early window (generally within the first hour or two). The ointment can temporarily blur the newborn's vision, so timing it after initial bonding is reasonable. It does not require refrigeration, a feeding, or any change in pupil size to work.
- A newborn born at 38 weeks weighs 4,300 grams, placing the weight above the 90th percentile for gestational age. How is this infant classified, and what is a priority assessment?
- Small for gestational age; monitor for polycythemia
- Post-term; monitor for meconium aspiration
- Appropriate for gestational age; no special monitoring
- Large for gestational age; monitor for hypoglycemia and birth injury
Correct answer: Large for gestational age; monitor for hypoglycemia and birth injury
This infant is large for gestational age (LGA), defined as a birth weight above the 90th percentile for gestational age. LGA infants, often born to mothers with diabetes, are at risk for hypoglycemia from hyperinsulinemia and for birth trauma such as shoulder dystocia, clavicle fracture, and brachial plexus injury. Being post-term refers to gestational age, not weight percentile.
- A nurse cares for an infant whose birth weight falls below the 10th percentile for gestational age. Which complication should the nurse anticipate most closely in the first hours of life?
- Hypoglycemia and difficulty with thermoregulation
- Hyperglycemia and excessive weight gain
- Delayed passage of meconium from large bowel size
- Macrosomia-related shoulder dystocia
Correct answer: Hypoglycemia and difficulty with thermoregulation
A small-for-gestational-age (SGA) infant, defined as birth weight below the 10th percentile for gestational age, is prone to hypoglycemia because of limited glycogen stores and to cold stress because of reduced subcutaneous fat and a high surface-area-to-mass ratio. Polycythemia is also common from chronic intrauterine hypoxia. Macrosomia and shoulder dystocia are concerns of large, not small, infants.
- A term newborn 90 minutes after birth has a temperature of 36.0 C, increased respiratory rate, mild grunting, and cool, mottled skin. The nurse recognizes cold stress. Which physiologic consequence is the newborn most at risk for if rewarming is delayed?
- Hypercalcemia and bradycardia
- Hyperglycemia and respiratory alkalosis
- Polycythemia and hypertension
- Hypoglycemia and metabolic acidosis
Correct answer: Hypoglycemia and metabolic acidosis
Cold stress drives nonshivering thermogenesis, which burns glucose and oxygen and produces hypoglycemia and, through anaerobic metabolism, metabolic acidosis. The increased oxygen demand and acidosis can also raise pulmonary vascular resistance and decrease surfactant production, worsening respiratory distress. Prompt rewarming and a neutral thermal environment reverse this cascade.
- A nurse is positioning a newborn under a radiant warmer and drying the infant immediately after a water birth. Drying the skin prevents heat loss through which mechanism?
- Conduction
- Convection
- Evaporation
- Radiation
Correct answer: Evaporation
Drying the wet newborn prevents heat loss by evaporation, the conversion of liquid on the skin to vapor. Conduction is heat lost to a cooler surface in direct contact, convection is heat carried away by moving air, and radiation is heat transferred to nearby cooler solid objects not in contact. Recognizing the four mechanisms guides interventions that maintain a neutral thermal environment.
- A nurse places a newborn's bassinet away from an exterior window and cold wall to minimize heat loss. Which mechanism of heat loss is this intervention specifically addressing?
- Metabolism
- Evaporation
- Conduction
- Radiation
Correct answer: Radiation
Keeping the infant away from a cold window or wall reduces radiant heat loss, which is heat transferred to cooler solid surfaces nearby even without direct contact. Warming surfaces the infant touches addresses conduction, drying addresses evaporation, and avoiding drafts addresses convection. Maintaining a neutral thermal environment minimizes the metabolic cost of staying warm.
- A nurse strokes the cheek of a quiet newborn, and the infant turns the head toward the stimulus and opens the mouth. Which reflex does this demonstrate, and what is its significance?
- Rooting reflex; supports the infant's ability to locate the nipple for feeding
- Sucking reflex; indicates readiness to swallow
- Tonic neck reflex; indicates normal posture
- Babinski reflex; indicates intact spinal pathways
Correct answer: Rooting reflex; supports the infant's ability to locate the nipple for feeding
Turning toward a cheek stroke and opening the mouth is the rooting reflex, which helps the newborn locate the nipple and is important for successful feeding. It normally fades by about 3 to 4 months. The sucking reflex is triggered by something touching the roof of the mouth, the tonic neck reflex is a fencing posture, and the Babinski reflex involves toe fanning when the sole is stroked.
- A nurse strokes the lateral sole of a newborn's foot from heel to toes and observes the great toe dorsiflex while the other toes fan outward. How should the nurse interpret this finding?
- An abnormal response requiring neurology referral
- A positive Ortolani sign
- A normal Babinski reflex expected in newborns
- A sign of hip dysplasia
Correct answer: A normal Babinski reflex expected in newborns
Dorsiflexion of the great toe with fanning of the other toes when the lateral sole is stroked is a normal positive Babinski reflex in the newborn, reflecting immature myelination of the corticospinal tract. It persists through infancy and typically disappears around 12 to 24 months; in older children and adults the same response is abnormal. The Ortolani sign and hip dysplasia involve the hip, not the foot.
- While holding a newborn upright with the soles touching a flat surface, the nurse observes the infant alternately flex and extend the legs as if walking. Which reflex is this?
- Palmar grasp reflex
- Moro reflex
- Galant reflex
- Stepping reflex
Correct answer: Stepping reflex
Alternating leg movements when the newborn is held upright with feet on a surface is the stepping (or walking) reflex, a normal newborn finding that disappears by about 4 to 8 weeks. The Galant (trunk incurvation) reflex is elicited by stroking along the spine, the palmar grasp by pressing the palm, and the Moro by a sudden change in position. Presence of expected reflexes indicates intact neurologic function.
- A nurse places a finger against the palm of a newborn, and the infant tightly curls the fingers around it. By approximately what age should this reflex normally disappear?
- By 1 week
- By 3 to 4 months
- By 12 months
- It persists for life
Correct answer: By 3 to 4 months
The palmar grasp reflex, in which the newborn curls the fingers around an object pressed into the palm, normally disappears by about 3 to 4 months as voluntary grasp develops. Persistence beyond about 6 months may indicate a neurologic problem. Tracking the appearance and disappearance of primitive reflexes is part of assessing neurologic maturation.
- A nurse is explaining the newborn metabolic screen to parents and they ask specifically about phenylketonuria (PKU). Which statement best describes PKU and its screening?
- PKU is an inherited inability to metabolize phenylalanine, detected on the heel-stick blood spot, ideally after feeding has begun
- PKU is a thyroid disorder detected only by ultrasound
- PKU is a hearing disorder detected by otoacoustic emissions
- PKU is a blood clotting disorder treated with vitamin K
Correct answer: PKU is an inherited inability to metabolize phenylalanine, detected on the heel-stick blood spot, ideally after feeding has begun
Phenylketonuria is an inherited metabolic disorder in which the infant cannot properly metabolize the amino acid phenylalanine, which can accumulate and cause intellectual disability if untreated. It is detected on the routine newborn heel-stick blood spot, which is most reliable after the infant has ingested protein (breast milk or formula), generally collected after 24 hours of age. Early detection allows a phenylalanine-restricted diet to prevent harm.
- A newborn metabolic blood spot is collected at 18 hours of life because the family is leaving early. What is the most appropriate nursing action?
- Cancel the screen and rely on physical examination
- Repeat the heel stick immediately within the same hour
- Document the early collection and arrange a repeat screen, often by about 1 to 2 weeks of age
- No further action is needed because the early sample is definitive
Correct answer: Document the early collection and arrange a repeat screen, often by about 1 to 2 weeks of age
A blood spot collected before 24 hours of feeding can produce false-negative results for some conditions such as PKU, so the early sample should be documented and a repeat screen arranged, commonly within the first one to two weeks. Newborn screening is a two-tier safety net, and a too-early specimen is not definitive. Physical examination cannot replace the metabolic panel.
- A nurse notes that a breastfed newborn has lost 7 percent of birth weight by day 3 of life. How should the nurse interpret and respond to this finding?
- This indicates an inborn error of metabolism
- This is within normal physiologic weight loss; continue to support feeding and monitor
- This indicates dehydration requiring formula supplementation now
- This exceeds normal limits; escalate immediately for IV fluids
Correct answer: This is within normal physiologic weight loss; continue to support feeding and monitor
A loss of about 5 to 7 percent of birth weight in the first few days is within the normal range of physiologic weight loss, which can reach up to about 7 to 10 percent in breastfed infants before regaining birth weight by 10 to 14 days. The nurse should support effective feeding and continue monitoring weight and output. Loss above roughly 10 percent or poor intake warrants further evaluation.
- A nurse compares two newborns. Infant A has a soft scalp swelling that crosses suture lines and was present at birth; Infant B has a firm swelling that does not cross suture lines and appeared several hours after birth. How should the nurse classify these?
- Both have subgaleal hemorrhage
- Both have molding
- Infant A has cephalohematoma; Infant B has caput succedaneum
- Infant A has caput succedaneum; Infant B has cephalohematoma
Correct answer: Infant A has caput succedaneum; Infant B has cephalohematoma
Infant A has caput succedaneum, edema of the scalp that crosses suture lines and is present at birth, resolving in a few days. Infant B has a cephalohematoma, a collection of blood under the periosteum that does not cross suture lines and often appears hours after birth, resolving over weeks and carrying a higher jaundice risk from blood breakdown. The key distinction is whether the swelling crosses suture lines.
- A nurse counts the umbilical cord vessels of a newborn and finds only two. What is the correct interpretation?
- This indicates immediate need for exchange transfusion
- The newborn has an extra vein requiring no action
- This is normal for a term newborn
- A single umbilical artery is present, which may be associated with congenital anomalies and warrants further assessment
Correct answer: A single umbilical artery is present, which may be associated with congenital anomalies and warrants further assessment
A normal umbilical cord contains three vessels, two arteries and one vein; finding only two vessels usually means a single umbilical artery. This finding can be associated with renal, cardiac, or other congenital anomalies, so it should be documented and the infant assessed further. It does not by itself require exchange transfusion.
- A nurse inspects the genitalia of a term female newborn and notes a small amount of blood-tinged vaginal discharge on day 2. What is the most appropriate interpretation?
- This is pseudomenstruation from maternal hormone withdrawal and is benign
- This indicates a bleeding disorder requiring vitamin K
- This indicates a urinary tract infection
- This is a sign of sexual abuse requiring a report
Correct answer: This is pseudomenstruation from maternal hormone withdrawal and is benign
Blood-tinged or mucoid vaginal discharge in a newborn female is pseudomenstruation, a benign effect of withdrawal from maternal estrogen after birth, and it resolves on its own. The same hormonal influence can cause transient breast enlargement in male and female newborns. It does not indicate a bleeding disorder, infection, or abuse.
- A nurse assesses a newborn and finds a respiratory rate of 78, intercostal retractions, nasal flaring, and audible grunting that persist beyond the first hour of life. What is the priority nursing action?
- Document as normal transition and reassess at discharge
- Recognize signs of respiratory distress and escalate for further evaluation and support
- Feed the infant to calm the breathing
- Apply eye prophylaxis
Correct answer: Recognize signs of respiratory distress and escalate for further evaluation and support
Persistent tachypnea over 60, retractions, nasal flaring, and grunting beyond the immediate transition period are signs of respiratory distress and require prompt evaluation and respiratory support, not reassurance. These findings may indicate transient tachypnea of the newborn, respiratory distress syndrome, infection, or other pathology. Feeding a distressed infant risks aspiration.
- A nurse observes a healthy term newborn during the first hours of life and notes the trunk and lips are pink while the hands and feet remain bluish. How should the nurse document and respond to this finding?
- Document central cyanosis and begin oxygen
- Document acrocyanosis, a normal finding, and continue routine care
- Document plethora and check a hematocrit
- Document mottling and obtain blood cultures
Correct answer: Document acrocyanosis, a normal finding, and continue routine care
Bluish hands and feet with a pink trunk and mucous membranes is acrocyanosis, a normal newborn finding caused by immature peripheral circulation that resolves over the first day or two. Central cyanosis, involving the lips, tongue, and trunk, is abnormal and signals hypoxia requiring intervention. Distinguishing peripheral from central cyanosis is a core newborn assessment skill.
- A nurse performs the Ortolani and Barlow maneuvers during a newborn assessment and feels a clunk on the Ortolani maneuver. What does this finding suggest?
- Normal hip stability
- A fractured clavicle
- Spina bifida
- Possible developmental dysplasia of the hip requiring further evaluation
Correct answer: Possible developmental dysplasia of the hip requiring further evaluation
A palpable clunk during the Ortolani maneuver, which relocates a dislocated femoral head into the acetabulum, suggests developmental dysplasia of the hip and warrants further evaluation, often with ultrasound. The Barlow maneuver assesses whether a reduced hip can be dislocated. These hip screening maneuvers are routine parts of the newborn musculoskeletal assessment.
- A nurse assesses a 36-hour-old newborn and finds jaundice that began on the face and has spread to the chest, with a transcutaneous bilirubin that plots in the high-risk zone for age in hours. What is the priority action?
- Place the infant in direct sunlight by a window
- Compare the bilirubin to the hour-specific threshold and notify the provider for possible phototherapy
- Stop breastfeeding permanently
- Reassure the parents that all jaundice is normal
Correct answer: Compare the bilirubin to the hour-specific threshold and notify the provider for possible phototherapy
The bilirubin must be interpreted against hour-specific thresholds using current AAP guidance, and a value in the high-risk zone warrants prompt provider notification and likely phototherapy. Jaundice appearing within the first 24 hours or rising rapidly is never assumed benign. Direct sunlight is unsafe and ineffective, and breastfeeding is usually continued during treatment.
- A nurse cares for a newborn of a mother whose blood type is O positive and the infant is A positive. The infant develops jaundice at 20 hours of life. Which process should the nurse suspect?
- Breast milk jaundice
- ABO incompatibility causing hemolysis
- Physiologic jaundice
- Vitamin K deficiency bleeding
Correct answer: ABO incompatibility causing hemolysis
Jaundice appearing within the first 24 hours in an O-positive mother with an A-positive infant suggests ABO incompatibility, in which maternal anti-A antibodies cross the placenta and hemolyze fetal red cells, raising bilirubin early. Physiologic jaundice appears after 24 hours, and breast milk jaundice appears later in the first weeks. Early-onset jaundice always warrants prompt evaluation.
- A nurse notes that a term newborn at 30 hours of life has not yet passed meconium. What is the most appropriate nursing action?
- Assume Hirschsprung disease and prepare for surgery
- Administer an enema immediately
- Document and continue to monitor, as most term newborns pass meconium within 24 to 48 hours
- Withhold all feedings
Correct answer: Document and continue to monitor, as most term newborns pass meconium within 24 to 48 hours
Most term newborns pass their first meconium within 24 to 48 hours of birth, so at 30 hours the nurse should document and continue monitoring while assessing for abdominal distension and feeding tolerance. Failure to pass meconium by 48 hours warrants evaluation for obstruction such as imperforate anus, meconium ileus, or Hirschsprung disease. Immediate enema or surgery is not indicated at 30 hours without other signs.
- A nurse assesses a term newborn's anterior fontanelle and finds it soft and slightly depressed when the infant is upright and crying, then flat when calm and supine. How should this be interpreted?
- A prematurely closed fontanelle
- A sunken fontanelle confirming severe dehydration
- A normal anterior fontanelle whose tension varies with position and crying
- A bulging fontanelle indicating increased intracranial pressure
Correct answer: A normal anterior fontanelle whose tension varies with position and crying
A soft, flat anterior fontanelle that may appear slightly depressed when the infant is upright or crying and flat when calm and supine is a normal finding. A persistently bulging fontanelle suggests increased intracranial pressure, while a persistently sunken one suggests dehydration; assessment is most accurate with the infant calm and upright. The anterior fontanelle normally closes by about 18 months.
- Using the current obstetric definition, postpartum hemorrhage is most accurately described as which of the following within 24 hours of birth?
- Any visible bleeding that soaks one perineal pad in 4 hours
- Any blood loss greater than 250 mL after a vaginal birth only
- Cumulative blood loss of 1,000 mL or more, or blood loss with signs or symptoms of hypovolemia, regardless of birth route
- Blood loss exceeding 500 mL after cesarean birth only
Correct answer: Cumulative blood loss of 1,000 mL or more, or blood loss with signs or symptoms of hypovolemia, regardless of birth route
Postpartum hemorrhage is defined as cumulative blood loss of 1,000 mL or more, or blood loss accompanied by signs or symptoms of hypovolemia, within 24 hours after birth regardless of delivery route. The single threshold applies to both vaginal and cesarean birth; blood loss over 500 mL is still considered abnormal and treated as an early-stage hemorrhage, but it is not the formal definition.
- A woman is 30 minutes post vaginal birth. The nurse notes a steady trickle of blood and palpates a fundus that is soft and difficult to locate. After fundal massage the uterus firms but quickly relaxes again. Which underlying problem do these findings most strongly indicate?
- A cervical laceration
- Uterine atony
- Retained placental fragments
- A coagulation disorder
Correct answer: Uterine atony
Uterine atony is the failure of the uterine muscle to contract and stay contracted, producing a soft, boggy uterus that bleeds and relaxes again after massage. It accounts for most early postpartum hemorrhage. A laceration bleeds with a firm fundus, and a coagulopathy bleeds despite a contracted uterus, so the boggy-then-relaxing pattern points to atony.
- A nurse caring for a postpartum patient palpates a boggy uterus with increased bleeding. The bladder is non-palpable and the woman voided 10 minutes ago. What is the most appropriate first nursing action?
- Place the patient in Trendelenburg position
- Administer a second-line uterotonic immediately
- Perform firm fundal massage while supporting the lower uterine segment
- Notify the rapid response team before any bedside intervention
Correct answer: Perform firm fundal massage while supporting the lower uterine segment
Firm fundal massage with the lower uterine segment supported is the immediate first action for a boggy uterus once a full bladder is ruled out, because mechanical stimulation often restores tone and controls bleeding. Medications are added if massage and bladder emptying do not work; supporting the lower segment during massage prevents uterine inversion.
- During management of postpartum hemorrhage from uterine atony, which intervention is considered the first-line pharmacologic uterotonic?
- Tranexamic acid
- Methylergonovine
- Carboprost
- Oxytocin
Correct answer: Oxytocin
Oxytocin is the first-line uterotonic for both prevention and initial treatment of postpartum hemorrhage caused by atony because it directly stimulates uterine contraction with a favorable safety profile. Methylergonovine and carboprost are second-line agents, and tranexamic acid is an antifibrinolytic adjunct, not a uterotonic.
- A bundle of nursing interventions is initiated for a patient with early postpartum hemorrhage. Which set of actions reflects the correct initial priorities?
- Massage the fundus, ensure the bladder is empty, establish IV access, and quantify blood loss
- Restrict fluids, place the patient flat, and reassess bleeding in one hour
- Administer methylergonovine first, then check the fundus
- Delay IV access until lab results return and apply only perineal ice
Correct answer: Massage the fundus, ensure the bladder is empty, establish IV access, and quantify blood loss
Initial postpartum hemorrhage nursing interventions are fundal massage, emptying the bladder, securing IV access for fluids and medications, and quantifying blood loss while monitoring vital signs. These address the most common cause (atony) and prepare for escalation. Restricting fluids or delaying IV access would worsen hypovolemia, and a vasoconstrictive ergot is not the automatic first step.
- Which combination of findings is most consistent with the early signs and symptoms of postpartum hemorrhage before vital signs change?
- A soft fundus, a steady trickle or gush of bright red lochia, and passage of large clots
- Afterpains relieved by emptying the bladder
- Pinkish-brown lochia serosa on day 4
- A firm fundus with scant lochia
Correct answer: A soft fundus, a steady trickle or gush of bright red lochia, and passage of large clots
Early postpartum hemorrhage signs include a soft or boggy fundus, persistent bright red bleeding or a sudden gush, and passage of large clots, often before tachycardia or hypotension appear because young healthy women compensate well. A firm fundus with scant lochia and normal lochia progression are expected findings, not warning signs.
- A nurse anticipates administering methylergonovine for postpartum hemorrhage. Which assessment must be completed and documented before giving this drug?
- Deep tendon reflexes
- Blood pressure
- Blood glucose level
- Respiratory rate only
Correct answer: Blood pressure
Blood pressure must be checked before methylergonovine because it is an ergot alkaloid that causes generalized vasoconstriction and can produce dangerous hypertension; it is contraindicated when blood pressure is elevated. The usual dose is 0.2 mg intramuscularly, and the nurse withholds it and notifies the provider if the patient is hypertensive.
- A postpartum patient with a history of asthma continues to bleed from atony after oxytocin and fundal massage. The provider considers carboprost. What is the nurse's most important consideration?
- Carboprost must be diluted and given as a slow IV push
- Carboprost can trigger bronchospasm and is used with caution or avoided in asthma
- Carboprost lowers blood pressure and should be avoided in hypotension only
- Carboprost is the safest choice specifically because of her asthma
Correct answer: Carboprost can trigger bronchospasm and is used with caution or avoided in asthma
Carboprost (a prostaglandin F2-alpha analog) can cause bronchoconstriction, so it is used with caution or avoided in patients with asthma due to the risk of life-threatening bronchospasm. It is given 250 mcg intramuscularly (not IV push), repeated every 15 to 90 minutes as needed. Common side effects also include fever, nausea, and diarrhea.
- A multiparous woman delivered a 4,200 gram infant after an oxytocin-augmented labor. Which combination places her at highest risk for postpartum hemorrhage from atony?
- Primiparity with a small infant
- Grand multiparity, macrosomia, and prolonged oxytocin exposure
- A precipitous labor with an average-size infant only
- Maternal age of 25 with a single gestation
Correct answer: Grand multiparity, macrosomia, and prolonged oxytocin exposure
Grand multiparity, fetal macrosomia, and prolonged oxytocin exposure all overdistend or fatigue the uterine muscle, markedly increasing the risk of atony and hemorrhage. Recognizing these stacked risk factors allows the nurse to prepare uterotonics and monitor closely after birth.
- A patient continues bleeding despite firm uterine tone, repair of a small laceration, and normal coagulation studies. The provider explores the uterus and finds adherent tissue. Which cause of hemorrhage does this finding represent?
- Vaginal hematoma
- Uterine atony
- Coagulopathy
- Retained placenta or placental fragments
Correct answer: Retained placenta or placental fragments
Retained placenta or retained placental fragments cause continued bleeding even when the uterus is firm, because the fragment prevents complete contraction and the placental site keeps bleeding. Management is removal of the tissue, often by manual extraction or curettage. This is distinct from atony, in which the entire uterus is soft.
- Following delivery, the placenta has not separated after 30 minutes and bleeding is increasing. The nurse understands that retained placenta is best defined as which of the following?
- Normal delivery of the placenta within 5 minutes
- Failure of the placenta to deliver within 30 minutes after birth of the infant
- Any placenta delivered with a missing membrane
- A placenta delivered in fragments that are all accounted for
Correct answer: Failure of the placenta to deliver within 30 minutes after birth of the infant
Retained placenta is failure of the placenta to deliver within about 30 minutes after the infant's birth, and it is a recognized cause of postpartum hemorrhage. It may result from a trapped, adherent, or abnormally invasive placenta, and management ranges from controlled cord traction to manual removal under appropriate analgesia.
- Immediately after the placenta delivers, the nurse sees a large, dark red mass protruding at the introitus, the patient becomes hypotensive and bradycardic, and the fundus cannot be palpated abdominally. What is the priority emergency?
- Amniotic fluid embolism
- Cervical laceration
- Uterine inversion
- Uterine atony
Correct answer: Uterine inversion
Uterine inversion presents as a protruding mass with sudden hemorrhage and often profound hypotension with vagally mediated bradycardia, and the fundus is no longer palpable in the abdomen. It is an obstetric emergency: uterotonics are stopped, IV access and fluids are ensured, and the provider attempts immediate manual replacement, sometimes with a tocolytic to relax the uterus.
- After a uterine inversion is manually replaced, which sequence of medication management is correct?
- Stop uterotonics and allow uterine relaxation for replacement, then restart uterotonics once the uterus is repositioned
- Give methylergonovine before and during replacement
- Avoid all uterotonics for 24 hours after replacement
- Continue uterotonics during replacement, then stop them afterward
Correct answer: Stop uterotonics and allow uterine relaxation for replacement, then restart uterotonics once the uterus is repositioned
For uterine inversion, uterotonics are withheld and the uterus may be relaxed with a tocolytic to allow the fundus to be pushed back into position; once the uterus is repositioned, uterotonics such as oxytocin are restarted to contract the uterus and prevent re-inversion and hemorrhage. Giving a uterotonic during replacement would tighten the cervical ring and obstruct the maneuver.
- A woman with severe preeclampsia is started on a magnesium sulfate infusion. What is the primary therapeutic purpose of this medication?
- To increase urine output
- To prevent and treat eclamptic seizures
- To promote uterine contraction
- To lower blood pressure to normal
Correct answer: To prevent and treat eclamptic seizures
Magnesium sulfate for preeclampsia is given primarily to prevent and treat eclamptic seizures through central nervous system depression, not as an antihypertensive. Blood pressure is managed separately with agents such as labetalol or hydralazine. A typical regimen is a 4 to 6 gram loading dose followed by 1 to 2 grams per hour.
- A nurse monitoring a patient on magnesium sulfate notes a serum magnesium level rising above the therapeutic range. Which assessment finding is the earliest reliable indicator of developing magnesium toxicity?
- Urine output of 40 mL/hr
- Cardiac arrest
- Respiratory rate of 8
- Loss of the patellar (deep tendon) reflexes
Correct answer: Loss of the patellar (deep tendon) reflexes
Loss of deep tendon reflexes is the earliest reliable warning sign of magnesium toxicity and precedes respiratory depression and cardiac effects, so reflexes are checked frequently. The therapeutic range is roughly 4 to 8 mg/dL; respiratory depression and cardiac arrest occur at higher levels, making absent reflexes the key early sign to act on.
- A patient receiving magnesium sulfate has a respiratory rate of 10, absent deep tendon reflexes, and slurred speech. After stopping the infusion, which medication should the nurse prepare as the antidote?
- Calcium gluconate
- Flumazenil
- Naloxone
- Protamine sulfate
Correct answer: Calcium gluconate
Calcium gluconate is the antidote for magnesium sulfate toxicity and is given intravenously after the infusion is stopped because calcium directly antagonizes magnesium at the neuromuscular junction. Naloxone, protamine, and flumazenil reverse opioids, heparin, and benzodiazepines respectively and have no role in magnesium toxicity.
- Which set of findings best represents the classic signs and symptoms of preeclampsia after 20 weeks of gestation?
- Hypertension that resolves with rest and has no laboratory changes
- New-onset hypertension with proteinuria or other end-organ signs such as headache, visual changes, and right upper quadrant pain
- Low blood pressure with weight loss
- Isolated lower extremity edema without hypertension
Correct answer: New-onset hypertension with proteinuria or other end-organ signs such as headache, visual changes, and right upper quadrant pain
Preeclampsia is new-onset hypertension after 20 weeks plus proteinuria or other end-organ involvement, and severe features include severe headache, visual disturbances, and right upper quadrant or epigastric pain. Dependent edema alone is nonspecific, and hypertension without these signs does not meet the diagnostic picture.
- A woman who was normotensive during pregnancy returns to the emergency department on postpartum day 5 with a blood pressure of 168/110, a pounding headache, and blurred vision. Which condition should the nurse suspect?
- Migraine without complications
- Postpartum preeclampsia
- Postpartum blues
- Normal postpartum diuresis
Correct answer: Postpartum preeclampsia
Postpartum preeclampsia is new-onset hypertension with severe features such as headache and visual changes that develops after delivery, typically within 48 hours but possible up to 6 weeks postpartum. It requires antihypertensive treatment and often magnesium sulfate for seizure prophylaxis, so these symptoms after discharge must be taken seriously rather than dismissed.
- A postpartum patient with severe preeclampsia suddenly develops tonic-clonic seizure activity. After ensuring airway and safety, which medication does the nurse anticipate administering or escalating?
- A benzodiazepine as the definitive long-term treatment
- Magnesium sulfate
- Methylergonovine
- A loop diuretic
Correct answer: Magnesium sulfate
Magnesium sulfate is the drug of choice to control and prevent recurrent eclamptic seizures; if the patient is not already receiving it, a loading dose is given, and if she is, an additional bolus may be ordered. During the seizure the nurse protects the airway, turns the patient to the side, and does not insert anything into the mouth.
- During an eclamptic seizure, which nursing action is appropriate to ensure patient safety?
- Restrain the extremities firmly
- Insert a padded tongue blade between the teeth
- Leave the bedside to call for the provider
- Turn the patient onto her side and protect her from injury
Correct answer: Turn the patient onto her side and protect her from injury
During an eclamptic seizure the nurse turns the patient to a side-lying position to maintain the airway and prevent aspiration, keeps the side rails up and padded, and stays with her to protect from injury while calling for help. Forcing objects into the mouth or restraining limbs can cause oral trauma and fractures and is contraindicated.
- A nurse reviews labs for a preeclamptic patient with epigastric pain and malaise. Which laboratory pattern confirms HELLP syndrome?
- Low hemoglobin with high platelets and normal liver enzymes
- Hemolysis, elevated liver enzymes, and low platelet count
- High platelets, low liver enzymes, and no hemolysis
- Elevated white count with normal liver enzymes
Correct answer: Hemolysis, elevated liver enzymes, and low platelet count
HELLP syndrome is defined by Hemolysis, Elevated Liver enzymes, and Low Platelets and is a severe variant of preeclampsia. Right upper quadrant or epigastric pain, nausea, and malaise are classic complaints. The low platelet count is especially important because it raises the risk of bleeding and influences anesthesia and delivery decisions.
- Which complaint reported by a patient with suspected HELLP syndrome most directly reflects the hepatic involvement of the disorder?
- Frequent urination
- Bilateral ankle swelling
- Lower back pain with contractions
- Right upper quadrant or epigastric pain
Correct answer: Right upper quadrant or epigastric pain
Right upper quadrant or epigastric pain in HELLP syndrome reflects liver involvement from periportal hemorrhage and hepatic capsule distension, and it can warn of impending hepatic rupture. Because this pain signals worsening disease, it must be reported and evaluated promptly rather than attributed to indigestion.
- A woman with severe preeclampsia being monitored for impending eclampsia develops sustained clonus and brisk hyperreflexia. How should the nurse interpret this finding?
- It indicates magnesium toxicity
- It is a normal postpartum reflex change
- It reflects an electrolyte deficiency unrelated to preeclampsia
- It signals increased central nervous system irritability and heightened seizure risk
Correct answer: It signals increased central nervous system irritability and heightened seizure risk
Hyperreflexia with sustained clonus reflects heightened central nervous system irritability and a rising risk of an eclamptic seizure, prompting reassessment of magnesium therapy and seizure precautions. This is the opposite of magnesium toxicity, which causes diminished or absent reflexes, so the distinction guides whether magnesium is escalated or held.
- A postpartum patient on day 3 has a temperature of 38.6 C, lower abdominal pain, uterine tenderness, and foul-smelling lochia. Which complication do these symptoms indicate?
- Urinary tract infection
- Mastitis
- Postpartum endometritis
- Deep vein thrombosis
Correct answer: Postpartum endometritis
Postpartum endometritis, an infection of the uterine lining, presents with fever (usually after the first 24 hours), uterine or lower abdominal tenderness, and foul-smelling lochia, often beginning on the second or third postpartum day. It is treated with broad-spectrum IV antibiotics, distinguishing it from mastitis, which causes a localized tender breast.
- Which patient has the greatest risk for developing postpartum endometritis?
- A woman who breastfeeds exclusively
- A woman with a postpartum hemoglobin of 12 g/dL
- A woman who had a spontaneous vaginal birth with intact membranes for 2 hours
- A woman who had a cesarean birth after prolonged rupture of membranes and multiple vaginal examinations
Correct answer: A woman who had a cesarean birth after prolonged rupture of membranes and multiple vaginal examinations
Cesarean birth, prolonged rupture of membranes, and multiple vaginal examinations are major risk factors for endometritis because they increase bacterial ascent and tissue trauma. Recognizing these risks lets the nurse monitor closely for fever and uterine tenderness and ensure timely antibiotic therapy.
- A postpartum patient develops a high fever, tachycardia, hypotension, confusion, and warm flushed skin on day 2. The nurse recognizes these as warning signs of which life-threatening complication?
- Postpartum sepsis
- Postpartum blues
- Normal postpartum diuresis
- Engorgement
Correct answer: Postpartum sepsis
Postpartum sepsis presents with fever, tachycardia, hypotension, altered mental status, and signs of poor perfusion as infection triggers a systemic inflammatory response. Early recognition and rapid treatment with fluids, broad-spectrum antibiotics, and source control are essential because sepsis is a leading cause of maternal death.
- When screening a postpartum patient for early sepsis, which combination of vital sign changes is most concerning for a systemic infectious response?
- Temperature 38.8 C, heart rate 118, respiratory rate 24, and falling blood pressure
- Mild night sweats with normal vital signs
- Blood pressure 120/76 with heart rate 64
- Temperature 37.0 C, heart rate 70, respiratory rate 16
Correct answer: Temperature 38.8 C, heart rate 118, respiratory rate 24, and falling blood pressure
Fever with tachycardia, tachypnea, and a falling blood pressure together suggest a systemic infectious response and possible early sepsis, warranting prompt escalation and a sepsis workup. Isolated normal readings or benign postpartum diaphoresis without vital sign derangement are not red flags for sepsis.
- A nurse is teaching about puerperal infection. Which statement accurately describes this condition?
- It is any infection of the genital tract occurring after childbirth, classically marked by fever of 38 C or higher on at least two occasions after the first 24 hours
- It refers only to breast infections during lactation
- It is a urinary infection unrelated to delivery
- It is a normal expected fever in the first 24 hours
Correct answer: It is any infection of the genital tract occurring after childbirth, classically marked by fever of 38 C or higher on at least two occasions after the first 24 hours
Puerperal infection refers to infection of the genital tract after childbirth, and puerperal fever is classically a temperature of 38 C or higher on at least two occasions, excluding the first 24 hours, between birth and 10 days postpartum. Endometritis is the most common form. A fever limited to the first day is often attributed to other causes such as dehydration.
- A postpartum patient reports unilateral leg pain, and the nurse notes calf swelling, warmth, redness, and tenderness on one side. Which complication do these signs and symptoms suggest?
- Sciatic nerve compression
- Normal postpartum dependent edema
- Cellulitis of the perineum
- Postpartum deep vein thrombosis
Correct answer: Postpartum deep vein thrombosis
Unilateral calf swelling, warmth, redness, and tenderness are classic signs of postpartum deep vein thrombosis, which is more likely because pregnancy and the postpartum period create a hypercoagulable state. The asymmetry is key, since normal postpartum edema is typically bilateral and painless.
- Which group of factors places a postpartum woman at highest risk for venous thromboembolism?
- Exclusive breastfeeding
- Early ambulation and adequate hydration
- A vaginal birth with immediate ambulation
- Cesarean birth, obesity, immobility, and a personal or family history of clotting disorder
Correct answer: Cesarean birth, obesity, immobility, and a personal or family history of clotting disorder
Cesarean birth, obesity, prolonged immobility, and a personal or family history of thrombophilia all add to the baseline postpartum hypercoagulable state, markedly raising the risk of deep vein thrombosis and pulmonary embolism. Early ambulation and hydration are protective, which is why they are encouraged after birth.
- A postpartum patient who delivered 8 hours ago suddenly reports sharp chest pain and shortness of breath, with a respiratory rate of 30 and oxygen saturation of 88 percent. What complication should the nurse suspect first?
- Endometritis
- Postpartum blues
- Mastitis
- Pulmonary embolism
Correct answer: Pulmonary embolism
Sudden dyspnea, pleuritic chest pain, tachypnea, and hypoxemia in a postpartum patient strongly suggest pulmonary embolism, a potentially fatal complication of the hypercoagulable postpartum state often arising from a deep vein thrombosis. Immediate actions include oxygen, rapid provider notification, and preparation for diagnostic imaging and anticoagulation.
- A woman 2 hours postpartum has a firm fundus and minimal lochia but reports severe, unrelenting perineal pain. The nurse observes a tense, bulging, discolored area at the vulva. Which complication is most likely?
- Normal perineal swelling
- Lochia rubra
- A urinary tract infection
- A vulvar or vaginal hematoma
Correct answer: A vulvar or vaginal hematoma
A tense, bulging, discolored mass with severe perineal pain and a firm fundus indicates a vulvar or vaginal hematoma, a form of concealed hemorrhage in which blood collects in the soft tissue rather than being expelled. Because the fundus is firm and external bleeding is minimal, the nurse must recognize that pain and a mass, not visible bleeding, are the key clues.
- A patient with abruptio placentae develops oozing from IV sites, gum bleeding, and bruising, with a falling fibrinogen and platelet count and prolonged clotting times. Which complication has developed?
- Mastitis
- Disseminated intravascular coagulation
- Uterine atony
- Postpartum blues
Correct answer: Disseminated intravascular coagulation
Disseminated intravascular coagulation is a consumptive coagulopathy in which widespread clotting depletes platelets and fibrinogen, producing bleeding from multiple sites with prolonged PT and PTT and elevated D-dimer. Placental abruption is a classic trigger, and treatment targets the underlying cause plus replacement of blood products and clotting factors.
- A laboring woman abruptly develops respiratory distress, hypotension, hypoxia, and then profuse bleeding with coagulopathy shortly after membrane rupture. Which rare obstetric emergency is most likely?
- Uterine atony
- Gestational hypertension
- Mastitis
- Amniotic fluid embolism
Correct answer: Amniotic fluid embolism
Amniotic fluid embolism is a rare, catastrophic event in which amniotic fluid enters the maternal circulation, causing sudden cardiorespiratory collapse, hypoxia, and disseminated intravascular coagulation. Management is immediate aggressive resuscitation and supportive care, and the nurse's role is rapid recognition and activation of the emergency response team.
- After a postpartum hemorrhage that required uterotonics and a transfusion, a woman later reports an inability to lactate, fatigue, and amenorrhea. Which complication should the nurse suspect?
- Postpartum thyroiditis only
- Engorgement
- Sheehan syndrome (postpartum pituitary necrosis)
- Normal lactation suppression
Correct answer: Sheehan syndrome (postpartum pituitary necrosis)
Sheehan syndrome is pituitary infarction caused by severe postpartum hemorrhage and hypotension, leading to deficiencies of pituitary hormones, classically failure of lactation along with fatigue and amenorrhea. Recognizing this link between a major hemorrhage and later endocrine symptoms allows timely referral for hormone evaluation and replacement.
- A nurse is using quantitative blood loss measurement during a birth complicated by bleeding. Why is this method preferred over visual estimation?
- It is faster and requires no equipment
- It is only used after the patient becomes unstable
- It more accurately determines actual blood loss and supports earlier recognition of hemorrhage
- It eliminates the need to monitor vital signs
Correct answer: It more accurately determines actual blood loss and supports earlier recognition of hemorrhage
Quantitative blood loss measurement, which combines weighing blood-soaked materials and measuring collected blood, is more accurate than visual estimation, which tends to underestimate larger losses. Earlier, more accurate measurement supports timely recognition and treatment of hemorrhage, though it is used alongside, not instead of, ongoing vital sign and clinical assessment.
- A postpartum patient has received oxytocin, methylergonovine, and carboprost with persistent bleeding from atony. Which intervention does the nurse anticipate next?
- Application of perineal ice only
- Discharge with oral iron
- Encouraging ambulation
- Placement of an intrauterine balloon tamponade device
Correct answer: Placement of an intrauterine balloon tamponade device
When uterotonics fail to control atonic bleeding, an intrauterine balloon tamponade device is a common next step to apply internal pressure to the uterine walls and reduce bleeding while preparing for possible surgical interventions. Ice and ambulation do not treat ongoing hemorrhage, so escalation to mechanical or surgical control is required.
- On postpartum day 10 a woman returns with persistent heavy bleeding, and the uterus is larger and softer than expected for this stage of involution. Which complication is most consistent with these findings?
- Normal involution
- Subinvolution of the uterus
- Mastitis
- Lochia alba
Correct answer: Subinvolution of the uterus
Subinvolution is delayed return of the uterus to its prepregnant size, often from retained placental fragments or infection, and presents with a larger, boggier uterus and prolonged or recurrent heavy lochia beyond the expected timeline. It is a cause of late (secondary) postpartum hemorrhage and is evaluated for retained tissue and treated accordingly.
- A nurse distinguishes postpartum blues from postpartum depression for a patient who is tearful on day 4. Which feature best characterizes postpartum blues rather than depression?
- Thoughts of harming the infant
- Symptoms that worsen and impair daily functioning beyond two weeks
- Symptoms that begin around day 2 to 5, are mild, and resolve on their own within about two weeks
- Persistent inability to care for the infant lasting more than a month
Correct answer: Symptoms that begin around day 2 to 5, are mild, and resolve on their own within about two weeks
Postpartum blues are mild, transient mood changes that begin around the second to fifth day, peak in the first week, and resolve on their own within about two weeks without impairing function. Postpartum depression involves more severe, persistent symptoms lasting beyond two weeks that interfere with functioning, which is the key distinction guiding referral.
- A patient at her postpartum visit reports that for the past three weeks she has felt persistently hopeless, cannot enjoy the baby, sleeps poorly even when the infant sleeps, and feels worthless. How should the nurse interpret these findings?
- These suggest postpartum depression requiring screening and referral for treatment
- These reflect a normal adjustment to motherhood
- These indicate normal fatigue and need only more rest
- These are expected postpartum blues that will resolve shortly
Correct answer: These suggest postpartum depression requiring screening and referral for treatment
Symptoms persisting beyond two weeks, with anhedonia, sleep disturbance, hopelessness, and feelings of worthlessness, point to postpartum depression rather than self-limited blues. The nurse should use a validated screening tool, assess safety, and arrange referral, because depression does not resolve without intervention the way blues do.
- A postpartum patient describes seeing and hearing things others do not, expresses bizarre beliefs about the baby, and is severely agitated on day 4. The nurse recognizes this as which condition requiring emergency care?
- Normal sleep deprivation
- Postpartum psychosis
- Mild postpartum anxiety
- Postpartum blues
Correct answer: Postpartum psychosis
Hallucinations, delusional beliefs about the infant, and severe agitation or disorganized thinking in the early postpartum period indicate postpartum psychosis, a rare psychiatric emergency with significant risk of harm to mother and infant. It requires immediate safety measures, supervision, and urgent psychiatric evaluation, unlike the mild self-limited course of postpartum blues.
- A woman 6 hours postpartum has voided well and has a firm fundus, but her heart rate is 120 and blood pressure is 92/56 with cool, clammy skin. Visible lochia is moderate. What is the priority nursing concern?
- Anxiety about the newborn
- Expected postpartum vital sign changes
- Mild dehydration that needs only oral fluids
- Possible concealed hemorrhage causing hypovolemia despite a firm fundus
Correct answer: Possible concealed hemorrhage causing hypovolemia despite a firm fundus
Tachycardia, hypotension, and cool clammy skin signal hypovolemia, and when the fundus is firm and visible bleeding is only moderate, a concealed source such as a hematoma or intra-abdominal bleeding must be considered. The nurse should rapidly reassess for hidden blood loss and escalate, because a firm fundus does not rule out hemorrhage.
- A patient with chronic hypertension is now 32 weeks pregnant with new proteinuria, worsening blood pressures, and a rising creatinine. How should the nurse interpret this change?
- Resolution of her hypertension
- Superimposed preeclampsia developing on chronic hypertension
- Gestational diabetes
- Normal late-pregnancy blood pressure variation
Correct answer: Superimposed preeclampsia developing on chronic hypertension
New-onset proteinuria, a sudden rise in blood pressure, and worsening organ function in a woman with pre-existing chronic hypertension indicate superimposed preeclampsia, which carries higher risk than either condition alone. Recognizing this shift triggers closer surveillance, possible magnesium sulfate, and planning for delivery timing.
- A nurse provides discharge teaching on postpartum warning signs. Which set of symptoms should the nurse instruct the patient to report immediately because they may signal a serious complication?
- Mild afterpains during breastfeeding and night sweats
- A severe persistent headache, vision changes, chest pain, leg swelling, heavy bleeding soaking a pad in an hour, or fever
- Breast fullness on day three
- Lochia changing from red to pink to white
Correct answer: A severe persistent headache, vision changes, chest pain, leg swelling, heavy bleeding soaking a pad in an hour, or fever
Patients should immediately report a severe or persistent headache, visual changes, chest pain or trouble breathing, a painful swollen leg, heavy bleeding soaking a pad in an hour, or a fever, because these can signal preeclampsia, embolism, thrombosis, hemorrhage, or infection. The other items describe expected postpartum changes that do not require urgent reporting.
- A patient is diagnosed with postpartum hemorrhage. In addition to uterotonics, the provider orders tranexamic acid. The nurse understands this medication works by which mechanism?
- It raises blood pressure through vasoconstriction
- It stimulates uterine muscle contraction directly
- It replaces depleted clotting factors
- It reduces clot breakdown by inhibiting fibrinolysis, helping stabilize clots
Correct answer: It reduces clot breakdown by inhibiting fibrinolysis, helping stabilize clots
Tranexamic acid is an antifibrinolytic that inhibits the breakdown of fibrin clots, helping stabilize existing clots and reduce ongoing blood loss in postpartum hemorrhage; it is most effective when given early. It is not a uterotonic and does not contract the uterus, so it is used as an adjunct alongside oxytocin and other uterotonics.
- Immediately after the placenta delivers, the nurse sees a large bluish-gray mass protruding from the vagina, the fundus is no longer palpable abdominally, and the woman becomes hypotensive and bradycardic. What is the priority emergency action?
- Apply vigorous fundal massage to the abdominal area
- Pull on the umbilical cord to deliver any remaining tissue
- Stop uterotonics, call for help, and prepare for immediate manual repositioning of the uterus
- Place the woman in a high Fowler position and give an oral analgesic
Correct answer: Stop uterotonics, call for help, and prepare for immediate manual repositioning of the uterus
Stopping uterotonics, calling for help, and preparing for immediate manual repositioning is the priority in uterine inversion. A uterus that cannot be palpated abdominally with a mass at or outside the introitus and profound shock signals inversion, a true emergency. Uterotonics are held because uterine relaxation is needed to replace the fundus, and a tocolytic such as terbutaline or nitroglycerin may be given to relax the uterus before reduction. Fundal massage and cord traction worsen the inversion.
- A woman develops uterine inversion after a vaginal birth. While preparing for manual replacement of the uterus, the provider requests a medication to relax the uterine muscle so the fundus can be repositioned. Which medication does the nurse anticipate?
- Methylergonovine intramuscularly
- Nitroglycerin or terbutaline
- Carboprost tromethamine
- Oxytocin infusion
Correct answer: Nitroglycerin or terbutaline
Nitroglycerin or terbutaline is anticipated because these tocolytics relax the uterine smooth muscle, allowing the inverted fundus to be pushed back into position. Uterotonics such as oxytocin, methylergonovine, and carboprost all contract the uterus and would make replacement harder, so they are withheld until after the uterus is restored. Once the fundus is replaced, uterotonics are then started to prevent the atony and hemorrhage that commonly follow inversion.
- A woman has not delivered the placenta 35 minutes after the birth of the infant despite controlled cord traction, and there is no active bleeding. The nurse recognizes this as which condition?
- Subinvolution
- Uterine inversion
- Retained placenta
- Placenta previa
Correct answer: Retained placenta
This is a retained placenta, generally defined as failure to deliver the placenta within about 30 minutes of birth despite active management of the third stage. It prevents the uterus from fully contracting and is a leading cause of postpartum hemorrhage and infection. Management may include emptying the bladder, a uterotonic, sometimes nitroglycerin to relax a trapped placenta, and manual removal if it does not deliver. Subinvolution and previa are unrelated to this timing.
- A nurse is performing the steps of active management of the third stage of labor to reduce the risk of postpartum hemorrhage. Which set of interventions best describes this approach?
- Withholding oxytocin until bleeding begins
- Immediate manual removal of the placenta in every birth
- Administering a prophylactic uterotonic, controlled cord traction, and uterine assessment
- Waiting for spontaneous placental delivery with no medications
Correct answer: Administering a prophylactic uterotonic, controlled cord traction, and uterine assessment
Active management of the third stage includes giving a prophylactic uterotonic (commonly oxytocin) soon after birth, controlled cord traction to assist placental delivery, and assessment of uterine tone. This bundle reduces the incidence and severity of postpartum hemorrhage compared with expectant management. Waiting passively or withholding the uterotonic until bleeding starts removes the protective effect, and routine manual removal is not part of normal management.
- A woman with continued postpartum hemorrhage from atony has not responded to fundal massage, oxytocin, methylergonovine, and carboprost. The provider plans a non-surgical mechanical intervention to control the bleeding. Which intervention does the nurse prepare for?
- Administration of Rho(D) immune globulin
- Application of a perineal ice pack
- Uterine balloon tamponade
- Repeat dose of methylergonovine
Correct answer: Uterine balloon tamponade
Uterine balloon tamponade is the next step when uterotonics fail to control atonic hemorrhage. A balloon device is placed in the uterine cavity and inflated to apply direct pressure against the uterine walls while preserving fertility. It is recommended as a second-line conservative measure before surgical options such as compression sutures or hysterectomy. Repeating uterotonics that have already failed or applying an ice pack would not control ongoing uterine bleeding.
- Tranexamic acid is recommended for postpartum hemorrhage. To maximize its benefit in reducing bleeding-related death, within what time frame from the onset of hemorrhage should it ideally be given?
- Only after 12 hours of bleeding
- Within 3 hours of the onset of bleeding
- After all uterotonics have failed for a full day
- Only at the time of hysterectomy
Correct answer: Within 3 hours of the onset of bleeding
Tranexamic acid should ideally be given within 3 hours of the onset of postpartum hemorrhage, as its mortality benefit declines significantly when administration is delayed beyond that window. It is an antifibrinolytic that stabilizes clots already formed and is used as an adjunct to uterotonics and other measures, not a replacement for them. Waiting many hours or until surgery markedly reduces its effectiveness.
- A nurse caring for a woman in early postpartum hemorrhage from a boggy uterus performs the most immediate independent nursing action. Which action is performed first?
- Insert an indwelling urinary catheter
- Establish a second large-bore IV line
- Massage the fundus while supporting the lower uterine segment
- Draw a type and crossmatch sample
Correct answer: Massage the fundus while supporting the lower uterine segment
Massaging the fundus while supporting the lower uterine segment is the first independent action for a boggy uterus. Manual stimulation prompts the uterus to contract and compress the open vessels at the placental site, often slowing or stopping atonic bleeding immediately. Supporting the lower segment with the opposite hand prevents uterine inversion during massage. Establishing IV access, drawing labs, and catheterizing follow but do not address the bleeding source as quickly.
- A nurse administers methylergonovine 0.2 mg intramuscularly to a postpartum woman for uterine atony. Which assessment is most important before and after giving this medication?
- Blood pressure
- Respiratory rate only
- Blood glucose level
- Deep tendon reflexes
Correct answer: Blood pressure
Blood pressure is the most important assessment with methylergonovine because it causes generalized vasoconstriction and can sharply raise blood pressure. It is contraindicated in women with hypertension or preeclampsia due to the risk of stroke. The nurse confirms the blood pressure is acceptable before administration and monitors it afterward. Blood glucose and deep tendon reflexes are not the primary concern with this ergot uterotonic.
- A nurse is preparing carboprost tromethamine for a woman with refractory uterine atony. Besides the asthma contraindication, which common side effect should the nurse anticipate and plan to manage?
- Hypoglycemia
- Diarrhea, nausea, and fever
- Urinary retention
- Severe bradycardia
Correct answer: Diarrhea, nausea, and fever
Diarrhea, nausea, and fever are common, anticipated side effects of carboprost because this prostaglandin F2-alpha analogue stimulates gastrointestinal smooth muscle and can affect temperature regulation. The nurse may give an antidiarrheal and antiemetic and reassure the woman that a transient temperature elevation can occur. Carboprost causes bronchospasm rather than bradycardia and does not characteristically cause hypoglycemia or urinary retention.
- A nurse administers oxytocin as a postpartum infusion to prevent and treat uterine atony. Which statement about postpartum oxytocin administration is accurate?
- It is given as an undiluted rapid IV push to stop bleeding fastest
- It is the antidote for magnesium toxicity
- It raises blood pressure and is avoided in low blood pressure
- It is diluted in IV fluid and infused, or given intramuscularly, to promote sustained uterine contraction
Correct answer: It is diluted in IV fluid and infused, or given intramuscularly, to promote sustained uterine contraction
Oxytocin is diluted in IV fluid and infused, or given intramuscularly, to promote sustained uterine contraction and control postpartum bleeding. Rapid undiluted IV push is avoided because it can cause hypotension and dysrhythmias. Oxytocin tends to lower blood pressure rather than raise it, and it has no role as a magnesium antidote. It remains the first-line agent for preventing and treating atony.
- A woman has rapid, uncontrolled atonic hemorrhage after a cesarean birth that does not respond to uterotonics or balloon tamponade. The surgeon performs a uterine compression suture to control bleeding while preserving the uterus. This procedure is known as which technique?
- Bakri insertion
- B-Lynch suture
- McDonald cerclage
- Episiotomy repair
Correct answer: B-Lynch suture
The B-Lynch suture is a uterine compression suture that mechanically compresses the uterus to control atonic hemorrhage while preserving the uterus and fertility. It is used when conservative measures such as uterotonics and balloon tamponade fail, before resorting to hysterectomy. A McDonald cerclage is a cervical stitch used in pregnancy, and a Bakri device is the balloon, not a suture.
- During an eclamptic seizure in a postpartum woman, what is the nurse's immediate priority?
- Leave the room to retrieve the magnesium sulfate from the pharmacy
- Protect the airway, turn her to her side, ensure oxygen and suction, and prevent injury
- Restrain the woman's limbs tightly to stop the movements
- Insert a padded tongue blade forcefully between clenched teeth
Correct answer: Protect the airway, turn her to her side, ensure oxygen and suction, and prevent injury
Protecting the airway by turning the woman to her side, providing oxygen, having suction ready, and preventing injury is the immediate priority during an eclamptic seizure. Side-lying reduces aspiration risk and improves perfusion. The nurse does not force objects between the teeth or restrain the limbs, as both can cause injury. Magnesium sulfate is the drug of choice to control and prevent further seizures and should already be accessible at the bedside.
- A postpartum woman on magnesium sulfate has a recurrent (breakthrough) eclamptic seizure despite the maintenance infusion. What does the nurse anticipate the provider will order?
- Reducing the magnesium infusion rate
- An additional magnesium sulfate bolus of 2 to 4 g
- Switching to oral antihypertensives only
- Discontinuing magnesium permanently
Correct answer: An additional magnesium sulfate bolus of 2 to 4 g
An additional magnesium sulfate bolus of 2 to 4 g is anticipated for a recurrent eclamptic seizure while the maintenance infusion continues. Breakthrough seizures are managed by re-bolusing magnesium, and a benzodiazepine may be added for refractory seizures. Stopping magnesium or merely lowering the rate would remove seizure protection, and oral antihypertensives do not stop seizure activity.
- A woman with preeclampsia develops right upper quadrant pain, malaise, and labs showing a hemoglobin drop with schistocytes, AST 180, and platelets of 72,000. The nurse recognizes the laboratory pattern of HELLP syndrome includes which three components?
- Hemolysis, elevated liver enzymes, and low platelets
- Hypofibrinogenemia, elevated D-dimer, and high creatinine
- High glucose, elevated lipase, and low potassium
- Hemoconcentration, elevated lactate, and leukocytosis
Correct answer: Hemolysis, elevated liver enzymes, and low platelets
HELLP syndrome consists of Hemolysis, Elevated Liver enzymes, and Low Platelets, which is what the acronym stands for. The hemolysis produces fragmented red cells (schistocytes) and a falling hemoglobin, elevated AST and ALT reflect liver involvement, and the platelet count falls below 100,000. It is a severe variant of preeclampsia that can appear or worsen postpartum and risks hepatic rupture and bleeding.
- A nurse explains the purpose of magnesium sulfate to a woman with preeclampsia with severe features. Which statement reflects the correct indication?
- It is used to lower the blood pressure quickly
- It speeds up involution of the uterus
- It is given to prevent and control seizures
- It treats the underlying liver dysfunction
Correct answer: It is given to prevent and control seizures
Magnesium sulfate is given to prevent and control seizures in preeclampsia and eclampsia; it is the first-line agent for seizure prophylaxis. It is not an antihypertensive, so separate agents such as labetalol or hydralazine are used to lower severe-range blood pressure. It does not affect uterine involution or directly treat HELLP-related liver dysfunction.
- A nurse is monitoring a postpartum woman receiving magnesium sulfate. Which sequence correctly reflects the progression of magnesium toxicity as serum levels rise?
- Cardiac arrest occurs before any reflex changes
- Loss of deep tendon reflexes occurs first, then respiratory depression, then cardiac arrest
- Urine output increases as levels rise
- Respiratory arrest occurs before loss of deep tendon reflexes
Correct answer: Loss of deep tendon reflexes occurs first, then respiratory depression, then cardiac arrest
As magnesium levels rise, loss of deep tendon reflexes occurs first, followed by respiratory depression, and finally cardiac arrest at the highest levels. This ordering is why the nurse checks deep tendon reflexes frequently as an early warning sign before respiratory status is compromised. Urine output tends to fall, not rise, because reduced output causes magnesium accumulation. Calcium gluconate is kept ready as the antidote.
- A nurse caring for a woman on magnesium sulfate is establishing the monitoring plan. Which parameters are most essential to assess regularly for early detection of toxicity?
- Deep tendon reflexes, respiratory rate, and urine output
- Pupil size and skin turgor
- Blood glucose and bowel sounds
- Lochia color and fundal height
Correct answer: Deep tendon reflexes, respiratory rate, and urine output
Deep tendon reflexes, respiratory rate, and urine output are the essential parameters for detecting magnesium toxicity early. Diminished or absent reflexes warn of rising levels, a respiratory rate below 12 signals depression, and adequate urine output (at least 30 mL/hr) ensures the kidneys are clearing magnesium. These three together allow the nurse to catch toxicity before it becomes life-threatening.
- A woman who was normotensive throughout pregnancy and at discharge returns to the emergency department 8 days after birth with a blood pressure of 158/106, swelling, and a headache. The nurse understands postpartum preeclampsia can occur up to what point after delivery?
- Only within the first 24 hours
- Up to 6 months postpartum
- Only during labor
- Up to about 6 weeks postpartum
Correct answer: Up to about 6 weeks postpartum
Postpartum preeclampsia can develop or worsen up to about 6 weeks after delivery, even in women who never had hypertension during pregnancy. Because most of these cases appear after hospital discharge, women must be taught the warning signs (severe headache, visual changes, right upper quadrant pain, swelling) and instructed to seek care promptly. It is not limited to the first 24 hours or to labor.
- A nurse reviews the classic signs and symptoms of preeclampsia with a pregnant woman at risk. Which combination best reflects preeclampsia with severe features?
- Hypoglycemia and cold intolerance
- Low blood pressure and excessive urination
- Blood pressure of 160/110 or higher, severe headache, visual changes, and right upper quadrant pain
- Bradycardia and weight loss
Correct answer: Blood pressure of 160/110 or higher, severe headache, visual changes, and right upper quadrant pain
Preeclampsia with severe features is reflected by a blood pressure of 160/110 or higher together with severe headache, visual disturbances, and right upper quadrant or epigastric pain, and may include thrombocytopenia or impaired liver and kidney function. These warning signs indicate end-organ involvement and the need for urgent antihypertensive treatment and magnesium for seizure prevention. Hypotension, bradycardia, and hypoglycemia are not features of preeclampsia.
- A nurse provides discharge teaching to a woman who had preeclampsia about when to have her blood pressure rechecked. Which follow-up timing reflects current recommendations?
- No follow-up is needed once discharged
- Follow-up only if she feels unwell
- Only at the routine 6-week visit
- A blood pressure check within about 72 hours and again at 7 to 10 days after birth
Correct answer: A blood pressure check within about 72 hours and again at 7 to 10 days after birth
A blood pressure check within about 72 hours and again at 7 to 10 days after birth reflects current recommendations for women with hypertensive disorders of pregnancy, because blood pressure often peaks several days postpartum. Waiting only for the 6-week visit or skipping follow-up entirely risks missing dangerous escalation. Early monitoring allows timely adjustment of antihypertensive therapy.
- A woman in labor suddenly develops acute hypoxia, hypotension, cardiovascular collapse, and then profuse bleeding with abnormal coagulation immediately after birth. Which life-threatening complication does the nurse suspect?
- Mastitis
- Bladder distension
- Amniotic fluid embolism
- Postpartum blues
Correct answer: Amniotic fluid embolism
Amniotic fluid embolism is suspected with the abrupt triad of hypoxia, hypotension or cardiovascular collapse, and coagulopathy occurring during labor or immediately after birth. It is a rare but catastrophic event caused by amniotic fluid components entering the maternal circulation and triggering an anaphylactoid-type reaction and disseminated intravascular coagulation. Management is supportive with aggressive resuscitation, oxygenation, and blood product replacement.
- A woman is 4 days postpartum and presents with fever of 38.5 C, tachycardia of 120, a respiratory rate of 24, and a white blood cell count that is elevated, in the setting of suspected uterine infection. The nurse recognizes these findings as concerning for which condition?
- Normal postpartum recovery
- Engorgement
- Postpartum blues
- Postpartum sepsis
Correct answer: Postpartum sepsis
Postpartum sepsis is concerning when fever, tachycardia, tachypnea, and an abnormal white blood cell count accompany a suspected infection source such as the uterus. These systemic inflammatory response findings signal that a localized puerperal infection may be progressing to sepsis, which requires prompt cultures, broad-spectrum antibiotics, and fluids. Recognizing early sepsis is critical because maternal sepsis is a leading cause of maternal death.
- A nurse is teaching about puerperal infection. Which definition best describes a puerperal infection?
- Any infection of the genital tract occurring after birth, classically with fever after the first 24 hours
- A viral illness contracted before pregnancy
- A urinary infection that resolves without treatment
- An infection limited to the breast tissue only
Correct answer: Any infection of the genital tract occurring after birth, classically with fever after the first 24 hours
A puerperal infection is any infection of the genital tract occurring after birth, classically defined by a fever of 38 C or higher on any two of the first ten days postpartum, excluding the first 24 hours. Endometritis is the most common form. While the breast and urinary tract can also become infected postpartum, the puerperal infection term centers on genital tract infection following childbirth.
- A nurse lists the cardinal signs and symptoms of postpartum endometritis for a new graduate. Which group of findings is correct?
- Sudden chest pain and dyspnea
- Calf pain and unilateral leg swelling
- Fever, uterine tenderness, tachycardia, and foul or purulent lochia, usually beginning 2 to 3 days after birth
- Painless bright red bleeding and a firm fundus
Correct answer: Fever, uterine tenderness, tachycardia, and foul or purulent lochia, usually beginning 2 to 3 days after birth
Fever, uterine (fundal) tenderness, tachycardia, and foul-smelling or purulent lochia, typically beginning 2 to 3 days after birth, are the cardinal signs of endometritis. It is the most common postpartum infection, especially after cesarean birth. Painless bleeding with a firm fundus suggests a laceration, calf findings suggest deep vein thrombosis, and sudden chest pain suggests pulmonary embolism, which are distinct complications.
- A woman is 3 days postpartum and reports sudden left calf pain. The nurse notes warmth, redness, swelling, and tenderness localized to that calf. Which findings are most characteristic of postpartum deep vein thrombosis?
- Cool, pale, pulseless foot
- Bilateral symmetric ankle edema with no pain
- Generalized itching and a rash
- Unilateral calf pain, warmth, swelling, and tenderness
Correct answer: Unilateral calf pain, warmth, swelling, and tenderness
Unilateral calf pain, warmth, swelling, and tenderness are most characteristic of postpartum deep vein thrombosis, reflecting clot formation in a deep leg vein during the hypercoagulable postpartum period. Bilateral symmetric edema is usually normal physiologic fluid shift, and a cool, pulseless, pale foot suggests arterial rather than venous occlusion. The nurse avoids massaging the leg and anticipates duplex ultrasound and anticoagulation.
- A woman delivered the placenta intact but continues to ooze blood despite a firm, contracted fundus and no visible laceration. Her platelet count is low and fibrinogen is decreased. Which category of the four T's of postpartum hemorrhage does this represent?
Correct answer: Thrombin
This represents Thrombin, the coagulation category of the four T's (Tone, Trauma, Tissue, Thrombin). Continued bleeding despite a firm fundus with an intact placenta and no laceration, combined with abnormal coagulation labs such as low platelets and fibrinogen, points to a clotting problem rather than atony, trauma, or retained tissue. Management targets the underlying coagulopathy and replaces blood products.
- A nurse explains postpartum hemorrhage to a nursing student. Which statement best answers what postpartum hemorrhage is?
- It is cumulative blood loss of 1,000 mL or more, or blood loss with signs of hypovolemia, within 24 hours of birth
- It is any vaginal bleeding that occurs during the first stage of labor
- It is bleeding that only occurs after a cesarean birth
- It is the normal lochia that lasts up to 6 weeks
Correct answer: It is cumulative blood loss of 1,000 mL or more, or blood loss with signs of hypovolemia, within 24 hours of birth
Postpartum hemorrhage is defined as cumulative blood loss of 1,000 mL or more, or any blood loss accompanied by signs and symptoms of hypovolemia, within 24 hours after birth regardless of delivery route. This replaced older route-specific thresholds. Normal lochia and intrapartum bleeding are different phenomena, and hemorrhage can follow either vaginal or cesarean birth.
- A nurse reviews early warning signs that may precede recognized postpartum hemorrhage. Which set of signs and symptoms should prompt heightened assessment for hemorrhage?
- Tachycardia, restlessness, lightheadedness, and a saturated pad in less than an hour
- Warm dry skin and slow capillary refill that improves
- Increased urine output and bradypnea
- Decreasing heart rate and rising blood pressure
Correct answer: Tachycardia, restlessness, lightheadedness, and a saturated pad in less than an hour
Tachycardia, restlessness, lightheadedness, and saturating a pad in under an hour are signs and symptoms that should prompt heightened assessment for postpartum hemorrhage. The body compensates for blood loss with an increased heart rate and early neurologic changes before blood pressure drops. Bradycardia, rising blood pressure, and increased urine output are not consistent with developing hemorrhage and hypovolemia.
- A woman with a retained, trapped placenta and a partially closed cervix is not actively bleeding. The provider orders a medication to relax the uterus and cervix to help the placenta deliver before resorting to manual removal. Which medication does the nurse anticipate?
- Carboprost
- Nitroglycerin
- Oxytocin bolus
- Methylergonovine
Correct answer: Nitroglycerin
Nitroglycerin is anticipated because it relaxes uterine and cervical smooth muscle, which can free a trapped placenta and reduce the need for manual removal under anesthesia. Uterotonics such as methylergonovine, carboprost, and oxytocin contract the uterus and would not relieve a constriction trapping the placenta. The nurse monitors blood pressure closely because nitroglycerin can cause hypotension.
- A nurse is differentiating postpartum depression from postpartum blues for a new mother and her partner. Which statement most accurately captures the difference?
- Depression always includes hallucinations
- Both resolve within a few days without any intervention
- Blues are mild and self-limited within about 2 weeks, while depression is more severe, persists beyond 2 weeks, and impairs functioning
- Blues require antidepressant medication
Correct answer: Blues are mild and self-limited within about 2 weeks, while depression is more severe, persists beyond 2 weeks, and impairs functioning
Postpartum blues are mild, common, and self-limited, peaking around days 3 to 5 and resolving within about 2 weeks, whereas postpartum depression is more severe, lasts longer than 2 weeks, and interferes with daily functioning and infant care. Hallucinations indicate psychosis, not typical depression, and the blues do not require medication. Teaching families this distinction helps them know when to seek further evaluation.
- A nurse reviews risk factors for postpartum hemorrhage to prioritize monitoring. Which woman is at the highest risk for uterine atony and hemorrhage?
- A woman with an overdistended uterus from twins and a prolonged, augmented labor
- A woman with a spontaneous vaginal birth and intact perineum
- A primipara with a 6-pound infant and a 6-hour labor
- A woman who breastfed immediately after birth
Correct answer: A woman with an overdistended uterus from twins and a prolonged, augmented labor
A woman with an overdistended uterus from a multiple gestation plus a prolonged, oxytocin-augmented labor is at highest risk for uterine atony and hemorrhage. Uterine overdistension and exhausted, overstimulated myometrium impair the contraction needed to clamp placental-site vessels. Early breastfeeding actually triggers natural oxytocin release, and an uncomplicated vaginal birth carries lower risk.
- A nurse caring for a postpartum woman with confirmed deep vein thrombosis is initiating anticoagulation. Which anticoagulant is generally preferred during the postpartum period, including for breastfeeding women?
- No anticoagulation, only bed rest
- Warfarin started immediately as the sole agent
- Direct oral anticoagulants as first choice while breastfeeding
- Low molecular weight heparin
Correct answer: Low molecular weight heparin
Low molecular weight heparin is generally preferred for treating postpartum venous thromboembolism, including in breastfeeding women, because it does not cross into breast milk in clinically significant amounts and has predictable dosing. Warfarin is compatible with breastfeeding but requires bridging and monitoring, and direct oral anticoagulants are generally avoided during lactation due to limited safety data. Bed rest alone does not treat an existing clot.
- A woman with postpartum hemorrhage requires rapid volume resuscitation. The nurse anticipates activation of a massive transfusion protocol. Which approach to blood product replacement does this protocol emphasize?
- Packed red blood cells only
- A balanced ratio of red cells, plasma, and platelets
- Albumin as the primary replacement
- Crystalloid fluids exclusively
Correct answer: A balanced ratio of red cells, plasma, and platelets
A massive transfusion protocol emphasizes a balanced ratio of packed red blood cells, fresh frozen plasma, and platelets to replace not only red cells but also the clotting factors and platelets consumed during severe hemorrhage. Giving red cells or crystalloid alone dilutes clotting factors and worsens coagulopathy. The balanced approach helps prevent the dilutional coagulopathy that perpetuates bleeding.
- A nurse assesses a postpartum woman 12 hours after birth and finds the fundus is two fingerbreadths above the umbilicus and deviated to the right, with increased lochia. After confirming a boggy uterus, what is the most likely contributing cause the nurse should address?
- Retained placenta
- Coagulopathy
- A distended bladder
- Cervical laceration
Correct answer: A distended bladder
A distended bladder is the most likely contributing cause when the fundus is displaced upward and to the right and becomes boggy. A full bladder physically prevents the uterus from contracting downward and firmly, leading to increased bleeding. Having the woman void or catheterizing as needed, followed by fundal massage, usually restores tone. This bladder-related displacement is a classic, readily reversible cause of early postpartum bleeding.
- A nurse is teaching a postpartum woman about lochia and warning signs after discharge. Which finding should the woman be told to report as a possible sign of complication?
- Lochia that progresses from rubra to serosa to alba
- A foul odor to the lochia or a return to heavy bright red bleeding after it had lightened
- Scant lochia alba in the third week
- Mild intermittent afterpains while breastfeeding
Correct answer: A foul odor to the lochia or a return to heavy bright red bleeding after it had lightened
A foul odor to the lochia, or a return to heavy bright red bleeding after it had lightened, should be reported because foul odor suggests infection (endometritis) and renewed heavy bleeding suggests subinvolution or retained tissue with delayed hemorrhage. The normal progression from rubra to serosa to alba, scant late lochia, and mild afterpains during breastfeeding are all expected and do not require reporting.
- A nurse is caring for a woman with severe-range postpartum hypertension who needs urgent blood pressure control. The provider orders intravenous hydralazine. Which response should the nurse monitor for after administration?
- Bronchospasm
- Marked bradycardia
- Reflex tachycardia and hypotension
- Hyperglycemia
Correct answer: Reflex tachycardia and hypotension
Reflex tachycardia and hypotension are the responses to monitor for after intravenous hydralazine, a direct vasodilator used for acute severe hypertension. The nurse rechecks blood pressure frequently after each dose and watches for an excessive drop and a compensatory rise in heart rate. Hydralazine does not characteristically cause bradycardia, hyperglycemia, or bronchospasm; bronchospasm is a concern with the beta-blocker labetalol in asthmatics.
- A nurse is differentiating septic pelvic thrombophlebitis from endometritis in a febrile postpartum woman. Which feature most strongly points to septic pelvic thrombophlebitis?
- Foul-smelling lochia that improves with antibiotics
- Dysuria and suprapubic pain
- Persistent spiking fevers that fail to respond after several days of appropriate antibiotics, with an otherwise improving exam
- A tender, red, wedge-shaped area on the breast
Correct answer: Persistent spiking fevers that fail to respond after several days of appropriate antibiotics, with an otherwise improving exam
Persistent spiking fevers that fail to respond after several days of appropriate antibiotics, despite an otherwise improving examination, most strongly point to septic pelvic thrombophlebitis. Infected thrombi in the pelvic veins cause this enigmatic fever pattern, and treatment adds anticoagulation to antibiotics. Improving foul lochia suggests resolving endometritis, breast findings suggest mastitis, and dysuria suggests a urinary infection.
- A nurse plans care for a woman at high risk for postpartum venous thromboembolism after a cesarean birth. Which preventive intervention is most appropriate to implement early?
- Sequential compression devices and early ambulation, with pharmacologic prophylaxis if indicated
- Keeping the legs in a dependent position continuously
- Strict bed rest for the first 48 hours
- Restricting oral fluids
Correct answer: Sequential compression devices and early ambulation, with pharmacologic prophylaxis if indicated
Sequential compression devices and early ambulation, with pharmacologic prophylaxis when indicated, are the most appropriate preventive interventions for venous thromboembolism after cesarean birth. These measures counter the venous stasis and hypercoagulability of the postpartum period. Strict bed rest, fluid restriction, and dependent leg positioning all promote stasis and increase, rather than decrease, clot risk.
- A nurse is reviewing the timing categories of postpartum hemorrhage. Which statement correctly distinguishes primary from secondary postpartum hemorrhage?
- Both occur only during the third stage of labor
- Primary occurs within the first 24 hours; secondary occurs from 24 hours up to 12 weeks postpartum
- Secondary occurs only after a cesarean birth
- Primary occurs after 24 hours; secondary occurs within 24 hours
Correct answer: Primary occurs within the first 24 hours; secondary occurs from 24 hours up to 12 weeks postpartum
Primary (early) postpartum hemorrhage occurs within the first 24 hours after birth and is most often due to uterine atony, while secondary (late or delayed) hemorrhage occurs from 24 hours up to 12 weeks postpartum and is usually caused by retained products or subinvolution. Knowing the timing guides the nurse toward the most likely cause. Secondary hemorrhage is not limited to cesarean births.
- A nurse is educating a woman who had postpartum depression with a prior pregnancy about her risk in this postpartum period. Which statement is most accurate?
- Only first-time mothers develop postpartum depression
- Postpartum depression cannot recur once treated
- A history of postpartum depression has no bearing on future risk
- A prior episode of postpartum depression substantially increases the risk of recurrence, so early screening and support are important
Correct answer: A prior episode of postpartum depression substantially increases the risk of recurrence, so early screening and support are important
A prior episode of postpartum depression substantially increases the risk of recurrence in subsequent pregnancies, so early screening, monitoring, and support are important for these women. A history of depression or other mood disorders is among the strongest predictors of postpartum depression. It can recur even after successful prior treatment and is not limited to first-time mothers.
- A nurse caring for a postpartum woman with preeclampsia notes brisk, 4+ deep tendon reflexes with clonus before magnesium sulfate is started. The nurse understands these findings most likely indicate what?
- Normal postpartum reflexes
- Hypocalcemia
- Magnesium toxicity
- Central nervous system irritability associated with worsening preeclampsia and increased seizure risk
Correct answer: Central nervous system irritability associated with worsening preeclampsia and increased seizure risk
Brisk, 4+ reflexes with clonus indicate central nervous system irritability associated with worsening preeclampsia and an increased risk of seizure, supporting the need for magnesium sulfate prophylaxis. These hyperactive findings are the opposite of magnesium toxicity, which causes diminished or absent reflexes. They are not a normal postpartum finding and are not explained by hypocalcemia in this setting.
- A newborn whose mother took methadone throughout pregnancy is 36 hours old and shows a high-pitched continuous cry, tremors when undisturbed, frequent sneezing, loose stools, and difficulty staying asleep after feeding. The nurse recognizes these as features of which condition?
- Physiologic jaundice
- Hypocalcemic tetany
- Neonatal abstinence syndrome
- Transient tachypnea of the newborn
Correct answer: Neonatal abstinence syndrome
Neonatal abstinence syndrome (also called neonatal opioid withdrawal syndrome) produces central nervous system irritability such as a high-pitched cry and tremors at rest, gastrointestinal disturbance such as loose stools, and autonomic signs such as sneezing in infants exposed to opioids in utero. The clustering of these findings, rather than a single sign, distinguishes withdrawal from isolated problems like jaundice or transient tachypnea.
- A nurse is caring for an infant with neonatal abstinence syndrome using the Eat, Sleep, Console approach. According to current practice, what is the first-line management before any pharmacologic treatment is considered?
- Immediate transfer to the neonatal intensive care unit
- Scheduled oral morphine every 4 hours
- Withholding all feedings until withdrawal scores decrease
- Nonpharmacologic care such as rooming-in, swaddling, low stimulation, and frequent feeding
Correct answer: Nonpharmacologic care such as rooming-in, swaddling, low stimulation, and frequent feeding
Nonpharmacologic care is the first-line treatment for neonatal abstinence syndrome and is effective alone in many infants. Measures such as rooming-in with the mother, swaddling, a quiet low-stimulation environment, skin-to-skin contact, and responsive frequent feeding are maximized first, with morphine added only as needed when the infant cannot eat, sleep, or be consoled. Scheduled medication is no longer the automatic starting point.
- An infant born by elective cesarean at 39 weeks develops a respiratory rate of 80 with mild grunting and nasal flaring at 1 hour of life. The chest is clear, the infant is otherwise pink, and symptoms gradually ease over the next 24 to 48 hours. Which condition best explains this presentation?
- Transient tachypnea of the newborn
- Congenital diaphragmatic hernia
- Respiratory distress syndrome from surfactant deficiency
- Meconium aspiration syndrome
Correct answer: Transient tachypnea of the newborn
Transient tachypnea of the newborn results from delayed clearance of fetal lung fluid and is more common after cesarean birth, especially without labor, because the thoracic squeeze and catecholamine surge of labor are reduced. It presents with tachypnea and mild distress that typically resolves within 24 to 72 hours. Surfactant-deficiency respiratory distress syndrome is a disease of prematurity and tends to worsen rather than steadily improve.
- A nurse is teaching a new graduate about transient tachypnea of the newborn. Which statement about the underlying cause is accurate?
- It is caused by a structural defect in the diaphragm
- It results from retained fetal lung fluid that has not been fully reabsorbed
- It is caused by aspiration of meconium-stained amniotic fluid
- It is caused by inadequate surfactant production in the alveoli
Correct answer: It results from retained fetal lung fluid that has not been fully reabsorbed
Transient tachypnea of the newborn is caused by delayed reabsorption of fetal lung fluid, which leaves the alveoli wet and reduces gas exchange efficiency. This is why the condition is self-limited and clears as the fluid is absorbed, in contrast to surfactant deficiency or meconium aspiration, which involve different mechanisms and a more prolonged course.
- A term infant of a mother with poorly controlled gestational diabetes weighs 4,350 grams. At 90 minutes of age, before the first feeding, the nurse should anticipate screening for which complication?
- Hypernatremia
- Hyperglycemia
- Hyperthermia
- Hypoglycemia
Correct answer: Hypoglycemia
Hypoglycemia is the expected risk in an infant of a diabetic mother. Chronic fetal exposure to maternal hyperglycemia drives fetal hyperinsulinemia, and when the maternal glucose supply is cut at birth, the persistently high insulin level rapidly lowers the newborn's blood glucose. Macrosomic infants of diabetic mothers therefore require early, scheduled glucose monitoring per protocol.
- A nurse is reviewing why an infant of a diabetic mother is prone to hypoglycemia after birth. Which physiologic explanation is correct?
- The infant has too few insulin receptors to use glucose
- The infant has an excess of glucagon driving glucose into cells
- The infant cannot produce any insulin of its own
- Persistent fetal hyperinsulinemia continues after the maternal glucose source is removed
Correct answer: Persistent fetal hyperinsulinemia continues after the maternal glucose source is removed
Infants of diabetic mothers develop fetal hyperinsulinemia in response to chronically elevated maternal glucose crossing the placenta. After delivery the maternal glucose supply stops abruptly, but the high insulin level persists for a time and continues to drive glucose into cells, causing hypoglycemia. This is why early feeding and glucose monitoring are emphasized in these infants.
- A nurse assesses a 2-hour-old newborn and notes jitteriness, a weak high-pitched cry, poor feeding, and temperature instability. A heel-stick glucose is low. These clinical signs are most consistent with which condition?
- Developmental hip dysplasia
- Hyperbilirubinemia
- Newborn hypoglycemia
- Choanal atresia
Correct answer: Newborn hypoglycemia
Newborn hypoglycemia signs include jitteriness or tremors, a weak or high-pitched cry, poor feeding, lethargy, temperature instability, and in severe cases apnea or seizures. Many of these signs are nonspecific, so a low heel-stick glucose in a symptomatic infant confirms the suspicion and prompts feeding or dextrose per protocol with a recheck.
- A nurse is teaching parents about the warning signs of low blood sugar in their newborn. Which set of findings should the nurse instruct them to watch for and report?
- Hard pellet-like stools and rapid weight gain
- Frequent hiccups and occasional sneezing
- Strong cry, vigorous feeding, and pink color
- Jitteriness, lethargy, poor feeding, and a weak or high-pitched cry
Correct answer: Jitteriness, lethargy, poor feeding, and a weak or high-pitched cry
Signs of newborn hypoglycemia include jitteriness, lethargy, poor feeding, a weak or high-pitched cry, sweating, and temperature instability. A vigorous cry and active feeding are reassuring rather than concerning, while hiccups and sneezing are normal. Recognizing the constellation of irritability plus feeding and tone changes prompts a glucose check.
- A nurse is explaining the normal blood glucose range for a newborn to a nursing student. Which statement about normal newborn glucose is most accurate?
- Newborn glucose is identical to adult fasting values from the moment of birth
- A transient physiologic dip occurs in the first hours, with targets of roughly 40 to 45 mg/dL or higher used during early screening
- Any value under 60 mg/dL always requires intravenous dextrose
- Newborn glucose must exceed 70 mg/dL at all times in the first day
Correct answer: A transient physiologic dip occurs in the first hours, with targets of roughly 40 to 45 mg/dL or higher used during early screening
Newborn glucose normally dips in the first hours of life as the infant transitions off the maternal supply, then stabilizes. Time-based screening uses roughly 40 mg/dL or higher in the first 4 hours and 45 mg/dL or higher from 4 to 24 hours as operational screening targets in at-risk infants. Newborn values are not equivalent to adult fasting levels at birth, and not every value under 60 requires intravenous treatment.
- A nurse notes that a newborn has developed a yellowish tint of the skin and sclera at 14 hours of life. The total serum bilirubin is rising rapidly. How should the nurse interpret jaundice appearing this early?
- Breast milk jaundice, which appears later
- Physiologic jaundice, which is expected and benign
- Normal newborn skin variation requiring no action
- Pathologic jaundice, which requires prompt evaluation
Correct answer: Pathologic jaundice, which requires prompt evaluation
Jaundice that appears in the first 24 hours of life is considered pathologic and warrants prompt bilirubin evaluation, because it commonly reflects a hemolytic process such as ABO or Rh incompatibility or G6PD deficiency. Physiologic jaundice, by contrast, appears after 24 hours, peaks around days 3 to 5, and follows a slower, predictable rise.
- A nurse is teaching parents the difference between physiologic and pathologic newborn jaundice. Which statement best describes physiologic jaundice?
- It is always caused by blood group incompatibility
- It is accompanied by anemia and an enlarged liver and spleen
- It appears after the first 24 hours, peaks around days 3 to 5, and resolves without treatment in most term infants
- It appears within the first 24 hours and rises rapidly
Correct answer: It appears after the first 24 hours, peaks around days 3 to 5, and resolves without treatment in most term infants
Physiologic jaundice typically appears after the first 24 hours, peaks around days 3 to 5 in term infants, and resolves on its own as the immature liver matures and bilirubin is cleared. Onset within the first 24 hours, an unusually rapid rise, or signs of hemolysis such as anemia and hepatosplenomegaly point instead to pathologic jaundice requiring evaluation.
- A nurse is caring for a 3-day-old infant with neonatal hyperbilirubinemia. Which physiologic factor most contributes to the newborn's tendency to accumulate unconjugated bilirubin?
- Rapid bowel transit eliminating all bilirubin
- A high red blood cell volume with shorter cell lifespan combined with immature hepatic conjugation
- Excessive production of conjugating liver enzymes
- Increased renal excretion of bilirubin
Correct answer: A high red blood cell volume with shorter cell lifespan combined with immature hepatic conjugation
Neonatal hyperbilirubinemia develops because newborns have a relatively high red blood cell mass with a shorter cell lifespan, producing more bilirubin, while the immature liver has limited capacity to conjugate it. Reabsorption of bilirubin from the gut (enterohepatic circulation) adds further load. These factors together explain the common rise in unconjugated bilirubin in the first days of life.
- When evaluating neonatal hyperbilirubinemia under current guidance, which combination of factors determines whether phototherapy is started?
- Gestational age, the hour-specific total serum bilirubin, and the presence of neurotoxicity risk factors
- Birth weight alone
- The infant's feeding method only
- Maternal age and parity
Correct answer: Gestational age, the hour-specific total serum bilirubin, and the presence of neurotoxicity risk factors
The decision to begin phototherapy is based on gestational age, the hour-specific total serum bilirubin plotted on a treatment threshold curve, and whether neurotoxicity risk factors are present. Risk factors such as gestational age under 38 weeks, low albumin, isoimmune hemolytic disease, or G6PD deficiency lower the treatment threshold. Birth weight or feeding method alone does not drive the decision.
- A nurse is caring for a newborn receiving phototherapy for hyperbilirubinemia. Which nursing intervention is essential during treatment?
- Apply lotion to the skin to enhance light penetration
- Keep the infant fully clothed to prevent chilling
- Apply eye shields, expose maximal skin surface, and monitor temperature and hydration
- Withhold all feedings until the bilirubin normalizes
Correct answer: Apply eye shields, expose maximal skin surface, and monitor temperature and hydration
During phototherapy the nurse applies opaque eye shields to protect the retina, exposes as much skin as possible to the light to maximize effectiveness, and closely monitors temperature and hydration because the infant is undressed and has increased insensible water loss. Feedings are continued, not withheld, to support bilirubin excretion, and lotions are avoided because they can cause burns.
- Parents ask the nurse how phototherapy actually lowers their newborn's bilirubin level. Which explanation is correct?
- It stops the liver from producing bilirubin
- It converts bilirubin in the skin into water-soluble forms that can be excreted in stool and urine
- It thickens the bile so bilirubin is stored in the gallbladder
- It destroys red blood cells so less bilirubin forms
Correct answer: It converts bilirubin in the skin into water-soluble forms that can be excreted in stool and urine
Phototherapy works by using specific wavelengths of light to convert unconjugated bilirubin in the skin into water-soluble photoisomers and lumirubin, which can be excreted in the stool and urine without requiring liver conjugation. It does not destroy red cells or halt bilirubin production; it provides an alternative pathway for elimination while the liver matures.
- A nurse is monitoring a newborn under intensive phototherapy for signs of acute bilirubin encephalopathy. Which early finding should prompt immediate provider notification?
- Loose greenish stools
- Lethargy with poor feeding and decreased muscle tone
- Six wet diapers in 24 hours
- Mild transient skin bronzing
Correct answer: Lethargy with poor feeding and decreased muscle tone
Early acute bilirubin encephalopathy presents with lethargy, hypotonia, and poor feeding before progressing to high-pitched cry, hypertonia, arching, and seizures. These neurologic changes signal that bilirubin is affecting the brain and require urgent evaluation and escalation of care. Loose stools and increased wet diapers are expected effects of effective phototherapy, not warning signs.
- A nurse is assessing jaundice in a darker-skinned newborn. Which technique provides the most reliable bedside assessment before laboratory confirmation?
- Rely on the parents' description of skin color
- Blanch the skin over a bony prominence and inspect the sclera and oral mucous membranes in good light
- Inspect only the diaper area
- Assume jaundice is absent if the infant is feeding well
Correct answer: Blanch the skin over a bony prominence and inspect the sclera and oral mucous membranes in good light
In infants with darker skin tones, jaundice is hard to judge by surface color alone, so the nurse blanches the skin over a bony area to reveal the underlying yellow hue and examines the sclera and oral mucous membranes in natural light. Visual assessment is only a screen, however, and a transcutaneous or total serum bilirubin measurement is needed to quantify the level and guide treatment.
- A breastfed infant is 4 days old and has visible jaundice but is feeding poorly, with fewer than four wet diapers a day and ongoing weight loss. The nurse recognizes this pattern as most consistent with which entity?
- Breast milk jaundice peaking at 2 weeks
- Pathologic hemolytic jaundice
- Conjugated hyperbilirubinemia from biliary obstruction
- Breastfeeding jaundice related to inadequate intake
Correct answer: Breastfeeding jaundice related to inadequate intake
Breastfeeding jaundice (also called suboptimal-intake or lack-of-breastfeeding jaundice) occurs in the first week when poor milk intake leads to fewer stools, increased reabsorption of bilirubin from the gut, and dehydration. The main intervention is to improve feeding effectiveness and frequency. This differs from breast milk jaundice, a later phenomenon in a thriving, well-fed infant that peaks around 2 weeks.
- A preterm infant born at 30 weeks develops worsening tachypnea, grunting, nasal flaring, and intercostal and substernal retractions within the first hours of life, with a chest radiograph showing a diffuse reticulogranular pattern. Which condition best explains these findings?
- Respiratory distress syndrome from surfactant deficiency
- Pneumothorax
- Transient tachypnea of the newborn
- Meconium aspiration syndrome
Correct answer: Respiratory distress syndrome from surfactant deficiency
Respiratory distress syndrome of the newborn results from surfactant deficiency in preterm infants, causing alveolar collapse, progressive distress, and a classic diffuse reticulogranular (ground-glass) appearance on radiograph. Unlike transient tachypnea, which is self-limited and more common after term cesarean birth, surfactant-deficiency disease typically worsens over the first hours and is treated with surfactant and respiratory support.
- A nurse is explaining respiratory distress syndrome to the parents of a preterm infant. Which statement correctly describes why this condition develops?
- The infant has too much fluid in the lungs from a cesarean birth
- The infant inhaled meconium during delivery
- A hole in the diaphragm allows abdominal organs into the chest
- Immature lungs lack sufficient surfactant, causing alveoli to collapse and increasing the work of breathing
Correct answer: Immature lungs lack sufficient surfactant, causing alveoli to collapse and increasing the work of breathing
Respiratory distress syndrome develops because the preterm lung has not yet produced adequate surfactant, the substance that lowers surface tension and keeps alveoli open. Without it, alveoli collapse with each breath, gas exchange falls, and the infant must work harder to breathe. This mechanism is distinct from meconium aspiration, retained lung fluid, or a diaphragmatic defect.
- A post-term infant is born through thick, particulate green amniotic fluid and develops respiratory distress with coarse crackles, a barrel-shaped chest, and cyanosis shortly after birth. Which condition is most consistent with this presentation?
- Transient tachypnea of the newborn
- Respiratory distress syndrome of prematurity
- Meconium aspiration syndrome
- Choanal atresia
Correct answer: Meconium aspiration syndrome
Meconium aspiration syndrome occurs when an infant inhales meconium-stained amniotic fluid into the lungs, often a post-term or stressed infant. Meconium obstructs airways, inactivates surfactant, and causes inflammation, producing respiratory distress, coarse crackles, a hyperinflated barrel chest from air trapping, and cyanosis. The history of thick particulate green fluid is a key clue.
- A nurse is present at the birth of a vigorous term infant delivered through meconium-stained amniotic fluid. The infant has a strong cry, good tone, and a heart rate above 100. What is the recommended initial management of this vigorous infant?
- Begin chest compressions to clear the airway
- Immediate routine endotracheal suctioning before any breaths
- Withhold all stimulation until the airway is cleared with a catheter
- Routine newborn care with warming, drying, and stimulation, intervening only if distress develops
Correct answer: Routine newborn care with warming, drying, and stimulation, intervening only if distress develops
Current neonatal resuscitation guidance no longer recommends routine endotracheal suctioning of a vigorous infant born through meconium-stained fluid. A vigorous infant with good tone, strong respiratory effort, and heart rate above 100 receives routine care including warming, drying, and stimulation, with airway clearance and further intervention reserved for the infant who is not vigorous or develops distress.
- A nurse assesses a 12-hour-old newborn and finds temperature instability, lethargy, poor feeding, and grunting respirations. The mother had prolonged rupture of membranes and an intrapartum fever. These findings are most suggestive of which condition?
- Normal transition
- Hypoglycemia from cold stress
- Neonatal sepsis
- Physiologic jaundice
Correct answer: Neonatal sepsis
Neonatal sepsis signs are often subtle and nonspecific, including temperature instability (either fever or hypothermia), lethargy, poor feeding, respiratory distress such as grunting, and apnea. Maternal risk factors such as prolonged rupture of membranes and intrapartum fever raise suspicion. Because the newborn immune system is immature, these findings warrant prompt evaluation and a sepsis workup.
- A nurse is teaching new staff to recognize early-onset neonatal sepsis. Which finding is a recognized warning sign rather than a normal newborn variation?
- Transient periodic breathing during sleep
- Temperature instability with lethargy and poor feeding
- Pseudomenstruation in a female infant
- Acrocyanosis that resolves with warming
Correct answer: Temperature instability with lethargy and poor feeding
Temperature instability combined with lethargy and poor feeding is a classic early warning sign of neonatal sepsis, which can also include respiratory distress, apnea, tachycardia or bradycardia, and color changes. By contrast, acrocyanosis, brief periodic breathing, and pseudomenstruation are normal newborn findings that do not signal infection.
- A newborn whose mother was colonized with group B streptococcus and did not receive adequate intrapartum antibiotic prophylaxis is being monitored. The nurse understands that this infant is at greatest risk for which complication?
- Developmental hip dysplasia
- Physiologic jaundice
- Caput succedaneum
- Early-onset neonatal sepsis
Correct answer: Early-onset neonatal sepsis
Inadequate intrapartum antibiotic prophylaxis in a group B streptococcus colonized mother leaves the infant vulnerable to early-onset neonatal sepsis, which can progress rapidly to pneumonia, meningitis, and septic shock within the first hours to days of life. Close monitoring for temperature instability, respiratory distress, and feeding changes is therefore essential in these infants.
- A nurse is performing newborn resuscitation. After drying, warming, positioning, and clearing the airway, the heart rate is 80 beats per minute and the infant is gasping. What is the priority next intervention?
- Initiate effective positive pressure ventilation
- Begin chest compressions
- Administer intravenous epinephrine
- Continue stimulation and observe
Correct answer: Initiate effective positive pressure ventilation
When the heart rate is below 100 after the initial steps, effective positive pressure ventilation is the priority, because inadequate ventilation is the most common reason a newborn fails to improve. Chest compressions are added only if the heart rate remains below 60 despite 30 seconds of effective ventilation, and epinephrine follows if compressions and ventilation are still insufficient.
- During neonatal resuscitation the heart rate remains 50 beats per minute after 30 seconds of effective positive pressure ventilation with chest rise. What is the appropriate next step?
- Administer oral glucose
- Lower the oxygen concentration to room air
- Begin chest compressions coordinated with ventilation
- Stop ventilation and observe
Correct answer: Begin chest compressions coordinated with ventilation
If the heart rate stays below 60 after 30 seconds of effective positive pressure ventilation that produces visible chest rise, chest compressions are started and coordinated with ventilation, typically at a 3-to-1 ratio. Compressions support circulation while ventilation continues, and intravenous epinephrine is considered if the heart rate remains below 60 despite this combined effort.
- A late-preterm infant born at 35 weeks is at increased risk for several complications compared with a term infant. Which set of complications should the nurse most anticipate?
- Polycythemia, hypertension, and obesity
- Macrosomia and post-term skin changes
- Hypoglycemia, hypothermia, hyperbilirubinemia, and feeding difficulty
- Choanal atresia and cleft palate
Correct answer: Hypoglycemia, hypothermia, hyperbilirubinemia, and feeding difficulty
Late-preterm infants, born between 34 and 36 weeks, are physiologically immature and are more prone to hypoglycemia, hypothermia from limited brown fat and large surface area, hyperbilirubinemia from immature hepatic conjugation, respiratory distress, and feeding difficulty from immature suck-swallow coordination. Recognizing this cluster guides closer monitoring even when the infant initially appears well.
- A small-for-gestational-age newborn at the 5th percentile for weight is admitted for monitoring. Beyond hypoglycemia, which additional complication is this infant most at risk for?
- Polycythemia and associated hyperviscosity
- Macrosomia
- Hypertension
- Excessive subcutaneous fat
Correct answer: Polycythemia and associated hyperviscosity
Small-for-gestational-age infants are at risk for hypoglycemia from low glycogen stores and also for polycythemia, which develops in response to chronic intrauterine hypoxia stimulating red blood cell production. The resulting high hematocrit increases blood viscosity, impairing perfusion and adding risk for hypoglycemia and respiratory distress. Thermoregulation is also harder because of limited fat stores.
- A newborn has a venous hematocrit of 68 percent and appears ruddy and lethargic with poor feeding. The nurse recognizes that this polycythemic infant is at greatest risk for which immediate complication?
- Dehydration as the only concern
- Hypertension requiring medication
- Hyperviscosity leading to impaired perfusion and hypoglycemia
- Anemia
Correct answer: Hyperviscosity leading to impaired perfusion and hypoglycemia
Polycythemia, generally defined as a central venous hematocrit of 65 percent or higher, increases blood viscosity and impairs perfusion of the brain, kidneys, and gut. The sluggish circulation and high red cell turnover also predispose the infant to hypoglycemia and hyperbilirubinemia. Monitoring glucose, hydration, and perfusion is essential, and partial exchange transfusion may be considered in severe symptomatic cases.
- A nurse is assessing a preterm infant being fed by gavage and notes increasing abdominal distension, bilious gastric residuals, bloody stools, and feeding intolerance. Which complication should the nurse suspect?
- Physiologic reflux
- Necrotizing enterocolitis
- Caput succedaneum
- Transient tachypnea of the newborn
Correct answer: Necrotizing enterocolitis
Necrotizing enterocolitis is an inflammatory and ischemic bowel condition most common in preterm infants. It presents with abdominal distension, feeding intolerance, bilious residuals, bloody stools, and systemic signs such as temperature instability and lethargy. Prompt recognition, stopping enteral feeds, gastric decompression, and provider notification are critical because the condition can progress to bowel perforation.
- A newborn at 1 hour of age is pink when crying but becomes cyanotic and struggles to breathe when quiet and attempting to nurse. A catheter cannot be passed through either naris. Which complication does this most likely represent?
- Transient tachypnea of the newborn
- Esophageal atresia
- Bilateral choanal atresia
- Pierre Robin cleft only
Correct answer: Bilateral choanal atresia
Bilateral choanal atresia is a bony or membranous blockage of the posterior nasal passages. Because newborns are obligate nasal breathers, the infant becomes cyanotic at rest and during feeding but pinks up while crying through the mouth. Inability to pass a catheter through the nares supports the diagnosis, which requires an oral airway and surgical evaluation.
- A newborn chokes, coughs, and becomes cyanotic with the first feeding attempt and has excessive frothy oral secretions. A feeding catheter coils back rather than passing into the stomach. Which complication should the nurse suspect?
- Gastroesophageal reflux
- Hirschsprung disease
- Esophageal atresia with tracheoesophageal fistula
- Pyloric stenosis
Correct answer: Esophageal atresia with tracheoesophageal fistula
Esophageal atresia, often with a tracheoesophageal fistula, presents with excessive oral secretions, choking and cyanosis at the first feeding, and a feeding catheter that cannot advance into the stomach and coils in the upper pouch. Oral feedings must be withheld and the provider notified, because aspiration is a serious risk until surgical correction.
- A nurse assesses a newborn 6 hours after a difficult shoulder dystocia delivery and notes that the left arm lies adducted and internally rotated with the forearm extended, and the Moro reflex is absent on that side. Which birth complication does this finding suggest?
- Fractured clavicle alone
- Brachial plexus injury (Erb palsy)
- Spinal cord transection
- Developmental hip dysplasia
Correct answer: Brachial plexus injury (Erb palsy)
A brachial plexus injury such as Erb palsy results from stretching of the upper plexus nerves during a difficult delivery, classically after shoulder dystocia. The affected arm is adducted and internally rotated with the forearm extended, giving a characteristic posture and an absent Moro on that side. The grasp reflex is usually preserved, distinguishing it from a complete lower plexus injury.
- A newborn delivered with forceps has a firm, fluctuant scalp swelling that does not cross the suture lines and appears to enlarge over the first day. The nurse recognizes this finding and understands that, unlike caput succedaneum, this lesion carries which added concern?
- It indicates a skull fracture in all cases
- It can contribute to hyperbilirubinemia as the trapped blood breaks down
- It resolves within a few hours without any effect
- It always requires emergency surgery
Correct answer: It can contribute to hyperbilirubinemia as the trapped blood breaks down
A cephalohematoma is bleeding between the periosteum and skull that does not cross suture lines and may enlarge after birth. As the collected blood is reabsorbed and broken down, it adds to the bilirubin load and can contribute to hyperbilirubinemia, so the nurse monitors for jaundice. It differs from caput succedaneum, which is scalp edema that crosses suture lines and resolves quickly.
- A nurse is monitoring a term newborn who was depressed at birth and required resuscitation after a sentinel hypoxic event during labor. Which finding would most concern the nurse for hypoxic-ischemic injury in the first day of life?
- Seizure activity, abnormal tone, and a depressed level of consciousness
- Mild acrocyanosis
- Vigorous feeding with strong reflexes
- Periodic breathing during sleep
Correct answer: Seizure activity, abnormal tone, and a depressed level of consciousness
Hypoxic-ischemic encephalopathy from a perinatal hypoxic event can present in the first day with seizures, abnormal tone (hypotonia or hypertonia), a depressed level of consciousness, and poor feeding. Recognizing these neurologic signs is important because eligible infants may benefit from therapeutic hypothermia. Vigorous feeding, mild acrocyanosis, and periodic breathing are reassuring rather than concerning.
- A nurse caring for a newborn whose mother had untreated syphilis recognizes the need to monitor for congenital infection. Which finding would be consistent with congenital syphilis?
- Bilateral clubfoot only
- Macrosomia and excess vernix
- Hepatosplenomegaly, a maculopapular or peeling rash, and snuffles (rhinitis)
- Isolated single palmar crease
Correct answer: Hepatosplenomegaly, a maculopapular or peeling rash, and snuffles (rhinitis)
Congenital syphilis can present with hepatosplenomegaly, a maculopapular rash that may peel especially on the palms and soles, persistent nasal discharge (snuffles), jaundice, and bone changes. Recognizing these signs prompts confirmatory testing and penicillin treatment. Macrosomia and an isolated palmar crease are not features of this congenital infection.
- A newborn exposed to maternal varicella around the time of delivery is monitored closely. Why is perinatal varicella exposure near birth considered especially dangerous for the newborn?
- It guarantees lifelong immunity with no treatment needed
- It causes immediate macrosomia
- The infant may not receive protective maternal antibodies in time and can develop severe disseminated disease
- It only causes a mild self-limited rash with no risk
Correct answer: The infant may not receive protective maternal antibodies in time and can develop severe disseminated disease
When a mother develops varicella shortly before or after delivery, the infant may be exposed to the virus before protective maternal antibodies have crossed the placenta. This leaves the newborn vulnerable to severe, potentially disseminated neonatal varicella. Such infants are monitored closely and may receive varicella immune globulin and antiviral therapy to reduce severity.
- A nurse notes that a newborn has not passed meconium by 48 hours of age and has progressive abdominal distension with bilious vomiting. Which complication should be suspected and reported?
- Transient tachypnea of the newborn
- Normal delayed stooling
- Physiologic jaundice
- Lower intestinal obstruction such as Hirschsprung disease or intestinal atresia
Correct answer: Lower intestinal obstruction such as Hirschsprung disease or intestinal atresia
Failure to pass meconium within the first 48 hours, especially with abdominal distension and bilious vomiting, suggests a lower intestinal obstruction such as Hirschsprung disease or intestinal atresia. Bilious vomiting in a newborn is never normal and signals obstruction below the ampulla of Vater, warranting prompt evaluation and surgical consultation.
- A newborn of a mother with poorly controlled diabetes is at risk for hypocalcemia in the first days of life. Which clinical finding would alert the nurse to neonatal hypocalcemia?
- Excessive sleepiness with no other signs
- Bradycardia and hypotonia
- Jitteriness, irritability, and in severe cases tremors or seizures
- Decreased respiratory rate
Correct answer: Jitteriness, irritability, and in severe cases tremors or seizures
Neonatal hypocalcemia, more common in infants of diabetic mothers and preterm or stressed infants, presents with neuromuscular irritability such as jitteriness, tremors, and in severe cases seizures. Because the signs overlap with hypoglycemia, glucose is checked first, but persistent jitteriness with a normal glucose should prompt evaluation of the calcium level.
- A nurse is teaching parents of a newborn who did not receive prophylactic vitamin K at birth. Which complication should the nurse explain this infant is at increased risk for?
- Choanal atresia
- Hypoglycemia
- Vitamin K deficiency bleeding (hemorrhagic disease of the newborn)
- Hyperbilirubinemia
Correct answer: Vitamin K deficiency bleeding (hemorrhagic disease of the newborn)
Newborns have low vitamin K stores and a sterile gut that cannot yet synthesize it, so without prophylactic vitamin K they are at risk for vitamin K deficiency bleeding, also called hemorrhagic disease of the newborn. This can manifest as unexplained bruising, bleeding from the cord or circumcision site, or intracranial hemorrhage, which is why the intramuscular injection is recommended.
- A newborn screening result returns positive for a metabolic disorder, and the 4-day-old infant has poor feeding, lethargy, vomiting, and an unusual body odor. The nurse recognizes these findings as most consistent with which type of complication?
- A musculoskeletal anomaly
- An inborn error of metabolism
- Normal newborn behavior
- A respiratory infection
Correct answer: An inborn error of metabolism
An inborn error of metabolism, such as maple syrup urine disease or an organic acidemia, can present in the first days of life with poor feeding, lethargy, vomiting, and a distinctive body or urine odor as toxic metabolites accumulate. Newborn screening helps identify these disorders early, and prompt confirmation and dietary or metabolic treatment can prevent serious neurologic harm.
- A nurse caring for a newborn who suddenly becomes apneic with central cyanosis and a falling heart rate that does not respond to tactile stimulation should take which immediate action?
- Administer oral glucose
- Obtain a rectal temperature first
- Begin positive pressure ventilation
- Reposition and wait several minutes
Correct answer: Begin positive pressure ventilation
Apnea with bradycardia and central cyanosis that does not respond to gentle stimulation is a respiratory emergency, and the priority is to begin positive pressure ventilation to restore oxygenation. Effective ventilation is the cornerstone of newborn resuscitation, and other steps such as temperature or glucose checks must not delay restoring adequate breathing.
- A newborn who was not promptly dried after birth becomes cool and develops increased respiratory effort, mild grunting, and a falling glucose. The nurse recognizes that cold stress in a newborn is dangerous primarily because of which physiologic chain of events?
- Nonshivering thermogenesis raises oxygen and glucose consumption, worsening hypoxia, acidosis, and hypoglycemia
- Cold causes immediate excessive sweating and dehydration
- Cold permanently damages brown fat with no metabolic effect
- Cold directly stops the heart within minutes
Correct answer: Nonshivering thermogenesis raises oxygen and glucose consumption, worsening hypoxia, acidosis, and hypoglycemia
Cold stress is dangerous because the newborn responds with nonshivering thermogenesis, metabolizing brown fat to generate heat. This greatly increases oxygen and glucose consumption, which can precipitate or worsen hypoxia, metabolic acidosis, respiratory distress, and hypoglycemia. Preventing heat loss by prompt drying, removing wet linens, and skin-to-skin or warmer care interrupts this harmful cascade.
- A nurse is caring for an asymptomatic large-for-gestational-age newborn at 2 hours of age. The infant has fed well at the breast within the first hour. Per current AAP guidance, what is the appropriate next step to screen for hypoglycemia in this at-risk infant?
- Screen only if the infant becomes jittery or has a high-pitched cry
- Give a routine bolus of dextrose gel before the first glucose check
- Wait until 12 hours of age before any glucose screening
- Obtain a point-of-care glucose 30 minutes after the first feeding
Correct answer: Obtain a point-of-care glucose 30 minutes after the first feeding
Obtaining a point-of-care glucose about 30 minutes after the first feeding is correct. The AAP screens at-risk infants (large- or small-for-gestational-age, infants of diabetic mothers, and late-preterm infants) by feeding within the first hour and checking glucose 30 minutes after that feed. Waiting until 12 hours or screening only when symptoms appear misses early hypoglycemia in these high-risk infants, and dextrose gel is reserved for documented low values, not routine prophylaxis.
- During the first 4 hours of life, an asymptomatic at-risk newborn has a point-of-care glucose result that prompts intervention. Per the AAP hypoglycemia algorithm, which value during this initial 0-to-4-hour window would fall in the actionable range requiring feeding and rescreening?
- A glucose of 60 mg/dL
- A glucose of 70 mg/dL
- A glucose of 30 mg/dL
- A glucose of 55 mg/dL
Correct answer: A glucose of 30 mg/dL
A glucose of 30 mg/dL is the actionable value. In the AAP algorithm for asymptomatic at-risk infants during the first 4 hours of life, glucose values between roughly 25 and 40 mg/dL prompt re-feeding and rechecking, with treatment intensified if values do not rise. Values of 55, 60, or 70 mg/dL are within the acceptable range and do not, by themselves, require intervention in this window. After 4 hours the lowest acceptable level rises to about 35 mg/dL.
- A breastfed newborn born at 37 weeks gestation develops visible jaundice. The infant has isoimmune hemolytic disease, which is recognized as a hyperbilirubinemia neurotoxicity risk factor. Under the 2022 AAP hyperbilirubinemia guideline, how does the presence of this risk factor affect phototherapy management?
- It raises the bilirubin threshold so phototherapy can be safely delayed
- It eliminates the need for phototherapy in favor of immediate exchange transfusion
- It has no effect on thresholds because the infant is full term
- It lowers the total serum bilirubin threshold at which phototherapy is started
Correct answer: It lowers the total serum bilirubin threshold at which phototherapy is started
The presence of a neurotoxicity risk factor lowers the phototherapy threshold. The 2022 AAP guideline sets total serum bilirubin treatment thresholds by gestational age and age in hours, and neurotoxicity risk factors (gestational age under 38 weeks, albumin below 3.0 g/dL, isoimmune or other hemolytic disease, G6PD deficiency, sepsis, or clinical instability) lower both the phototherapy and escalation-of-care thresholds. Such risk factors never raise thresholds or remove the need for phototherapy, and exchange transfusion is reserved for much higher bilirubin levels or failed intensive phototherapy.
- A newborn whose mother used opioids during pregnancy is being assessed for neonatal opioid withdrawal syndrome using the Eat, Sleep, Console approach. Which finding would most strongly indicate the need to consider initiating pharmacologic treatment?
- The infant yawns frequently but settles to sleep for more than an hour at a time
- The infant has mild tremors that stop when swaddled and held
- The infant has occasional sneezing but feeds and sleeps adequately
- The infant cannot be consoled within about 10 minutes despite consistent nonpharmacologic measures
Correct answer: The infant cannot be consoled within about 10 minutes despite consistent nonpharmacologic measures
An infant who cannot be consoled despite consistent nonpharmacologic measures signals the possible need for medication. The Eat, Sleep, Console model focuses on whether the infant can eat adequately, sleep for sustained stretches, and be consoled, prioritizing nonpharmacologic care such as swaddling, low stimulation, and parental presence; pharmacologic treatment is reserved for infants who cannot achieve these functional goals. Isolated mild signs such as sneezing, yawning, or tremors that resolve with comforting do not by themselves require medication.
- A term newborn born at 39 weeks shows signs consistent with moderate hypoxic-ischemic encephalopathy following a difficult delivery with documented perinatal acidosis. The newborn is now 3 hours old. Which intervention is the recognized neuroprotective standard of care for this infant?
- Initiating therapeutic hypothermia to a core temperature near 33.5 degrees C and continuing it for 72 hours
- Delaying any cooling decision until the infant is at least 24 hours old
- Providing only routine thermoregulation because cooling is contraindicated at term
- Warming the infant aggressively to maintain a temperature above 37.5 degrees C
Correct answer: Initiating therapeutic hypothermia to a core temperature near 33.5 degrees C and continuing it for 72 hours
Initiating therapeutic hypothermia to a core temperature near 33.5 degrees C for 72 hours is the standard of care. For infants at or above 36 weeks gestation with moderate-to-severe hypoxic-ischemic encephalopathy, cooling must begin within 6 hours of birth to reduce death and moderate-to-severe neurodevelopmental impairment, so identifying eligibility promptly is essential. Aggressive warming worsens injury, and waiting until 24 hours misses the narrow 6-hour treatment window; cooling is indicated, not contraindicated, in eligible term infants.
- A nurse is monitoring a term newborn whose mother had inadequate intrapartum group B streptococcus prophylaxis. At 6 hours of age the infant develops tachypnea, temperature instability, and lethargy. What do these findings most likely indicate?
- Benign physiologic jaundice presenting early
- Expected behavior of a sleepy breastfed newborn
- Early-onset neonatal sepsis requiring prompt evaluation and empiric antibiotics
- Normal transition that resolves without intervention
Correct answer: Early-onset neonatal sepsis requiring prompt evaluation and empiric antibiotics
Tachypnea, temperature instability, and lethargy in this at-risk newborn point to early-onset neonatal sepsis. Group B streptococcus is a leading cause of early-onset sepsis, which usually presents within the first 24 hours; respiratory distress, temperature instability (often hypothermia in neonates), tachycardia, and poor feeding or lethargy are key warning signs that warrant cultures and empiric antibiotics. These are not features of normal transition, a sleepy feeder, or physiologic jaundice, and delaying evaluation can allow rapid clinical deterioration.
