Question

A nurse is caring for a client who is 12 hr postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

Answer 1

Correct Answers:

Heart rate 110/min

Rationale :

❤️Tachycardia (HR 110/min) at 12 hours postpartum can be an early sign of a postpartum complication, such as hemorrhage, infection, or hypovolemia.

🚨Although mild tachycardia can occur from pain or exertion, persistent or unexplained elevation in heart rate requires immediate evaluation to rule out more serious causes.

🩺Other findings such as orthostatic hypotension, fundus at the umbilicus, and urine output of 3,000 mL in 12 hr can be normal variations during early postpartum recovery.

🔍Close monitoring and further assessment are essential, as tachycardia may be the first visible sign before other vital changes manifest.

📌Core Message

A sustained elevated heart rate in the early postpartum period may signal a complication such as hemorrhage or infection and warrants prompt assessment.

Answer 2

Correct Answers:

Palpate the client's uterine fundus.

Rationale :

🖐️Palpating the uterine fundus is the priority action when a client has excessive postpartum bleeding because uterine atony is the most common cause of early postpartum hemorrhage.

🩸A soft or "boggy" uterus may indicate poor uterine contraction, allowing excessive blood loss from the placental site.

🧭Immediate assessment of the fundus allows the nurse to determine whether fundal massage or further interventions are needed to restore uterine tone and reduce bleeding.

🚫Although increasing fluids, giving oxytocics, or helping the client void may be necessary later, they are not the first priority without determining the uterine status.

📌Core Message

Always assess the uterine fundus first in cases of postpartum hemorrhage to detect and address uterine atony promptly.

Answer 3

Correct Answers:

Fundus palpable to right of midline

Rationale :

🧭A fundus that is displaced to the right of midline strongly indicates a distended bladder, which can interfere with uterine contraction and increase the risk for postpartum hemorrhage.

⭕The full bladder pushes the uterus to the side, preventing it from remaining firm and centrally located—its expected position after delivery.

🩺This displacement is a physical sign that requires prompt intervention, usually assisting the client to void to restore proper uterine tone and position.

🚫Increased thirst, light lochia, or uterine contractions do not indicate bladder distension and are common or expected postpartum findings.

📌Core Message

A deviated uterine fundus, especially to the right, is a key sign of a distended bladder that may hinder postpartum recovery.

Answer 4

Correct Answers:

Initiate early feeding.

Rationale :

🍼Early feeding promotes regular stooling, which helps the newborn excrete bilirubin through the gastrointestinal tract and prevents the buildup that leads to jaundice.

🧬Bilirubin is a byproduct of red blood cell breakdown, and feeding stimulates gut motility, reducing enterohepatic circulation and lowering bilirubin reabsorption.

⏰Initiating feedings within the first hours after birth is an evidence-based strategy to reduce the risk of physiologic jaundice.

🚫Suctioning mucus, exchange transfusion, and phototherapy are not preventive measures; the last two are treatments for already elevated bilirubin levels.

📌Core Message

Early feeding helps prevent neonatal jaundice by promoting bilirubin elimination through frequent stooling.

Answer 5

Correct Answers:

Cephalhematoma

Rationale :

🧠A cephalhematoma is a collection of blood between the skull bone and periosteum, which appears as a raised, bruised area that does not cross suture lines.

🩸It is caused by birth trauma, such as pressure during delivery, and typically appears hours after birth, often on one side of the scalp.

🔍The key distinguishing feature is that it is confined to one cranial bone, unlike caput succedaneum, which is diffuse and crosses suture lines.

🚫Pilonidal dimples are found near the sacrum, and molding refers to cranial shape changes from overlapping sutures, not localized swelling or bruising.

📌Core Message

A cephalhematoma is a localized scalp swelling from birth trauma that does not cross suture lines, differentiating it from other head findings.

Answer 6

Correct Answers:

"The primary consideration is what type of incision was performed this time."

Rationale :

🔍The type of uterine incision performed during a cesarean birth is the key factor in determining whether a vaginal birth after cesarean (VBAC) is a safe option in the future.

✂️A low transverse uterine incision is generally considered safe for a trial of labor because it carries the lowest risk of uterine rupture.

📋Other incisions, such as vertical or classical, may contraindicate VBAC due to higher risk of complications during future labor.

🚫Telling the client to "ask the obstetrician" or dismissing the question undermines client education, and saying that a repeat cesarean is always safer is not evidence-based.

📌Core Message

The type of uterine incision is the most important factor in determining VBAC eligibility and safety in future pregnancies.

Answer 7

Correct Answers:

Dry the skin

Rationale :

🌡️After establishing a patent airway, the priority action is to dry the newborn’s skin to prevent heat loss through evaporation, which can lead to hypothermia.

👶Newborns are highly vulnerable to cold stress due to their large body surface area and limited ability to regulate body temperature.

🧼Drying the skin also stimulates breathing and promotes circulation, making it a critical part of immediate post-birth care.

🚫While identification, eye prophylaxis, and vitamin K are important, they come after stabilization and thermal protection.

📌Core Message

After airway clearance, the nurse must dry the newborn's skin promptly to prevent hypothermia and support thermoregulation.

Answer 8

Correct Answers:

"I'll make sure his diaper is loose in the front:
"I'll expect the plastic ring to fall off by itself within a week."
"I'll call the doctor if I see any bleeding."

Rationale :

🍼Loose diapers help prevent pressure or friction on the Plastibell device, which reduces the risk of dislodging it or causing discomfort and promotes proper healing of the circumcision site.

🚼The Plastibell ring typically detaches and falls off spontaneously within 5 to 8 days, and parents should understand that no manual removal is necessary, which reflects normal healing progression.

🔴Parents should be advised to monitor for signs of complications, and bleeding is not normal—even minor bleeding can indicate improper healing or device dislodgement, requiring immediate medical attention.

💧Petroleum jelly is not used with the Plastibell method because it can cause the ring to loosen prematurely; it is typically used only with the Gomco clamp or Mogen clamp methods.

🧼Using soap on the circumcision site is contraindicated during healing as it may cause irritation; only warm water should be used to gently cleanse the area.

📌Core Message

Loose diapering, natural detachment of the Plastibell ring, and reporting bleeding are essential for safe circumcision care with the Plastibell technique.

Answer 9

Correct Answers:

"Have the mother call and I will take the baby to the room."

Rationale :

🔒Infant security is a top priority in the nursery setting, and only authorized staff should transport newborns to prevent infant abduction or misidentification.

📞By instructing the mother to call, the nurse ensures that the request is confirmed directly with the infant’s legal guardian and allows the nurse to maintain accountability for the baby’s safety.

🚫Allowing family members, even grandparents, to carry or transport the newborn, even with ID or in a bassinet, violates protocol designed to safeguard newborns from potential harm or security breaches.

🧑‍⚕️This approach reinforces institutional policies that prioritize controlled handling of infants by trained personnel, thus minimizing the chance of errors or unauthorized removal of the child.

📌Core Message

Newborn transport should only be done by authorized staff to ensure infant safety and uphold security protocols.

Answer 10

Correct Answers:

"I should remove extra blankets from my babys crib."

Rationale :

🛏️Removing extra blankets reduces the risk of suffocation and sudden infant death syndrome (SIDS), which is strongly associated with soft bedding and loose items in the sleep environment.

⚠️Safe sleep guidelines recommend that the baby sleep in a crib with a firm mattress and only a tightly fitted sheet—no pillows, toys, or loose bedding—to create a safe sleep space.

🌡️Placing the crib next to a heater poses a burn hazard and can lead to overheating, which is another risk factor for SIDS.

❌Placing a baby on the stomach to sleep contradicts current recommendations; supine (back) sleeping is the safest sleep position for infants.

🧸Padding the crib mattress is unsafe and unnecessary, as a firm surface is essential for proper infant positioning and to reduce the risk of positional asphyxia.

📌Core Message

Safe infant sleep involves using a firm crib mattress, keeping the area free of extra blankets, and placing the baby on their back to prevent SIDS.

1 :
A nurse is caring for a client who is 12 hr postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

2 :
A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time?

3 :
A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

4 :
A nurse is caring for a newborn 4 hr after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?

5 :
A nurse is assessing a newborn the day after delivery. The nurse notes a raised, bruised area on the left side of the scalp that does not cross the suture line. How should the nurse document this finding?

6 :
A nurse is caring for a client who delivered a healthy term newborn via cesarean birth. The client asks the nurse, "Is there a chance that I could deliver my next baby without having a cesarean section?' Which of the following responses should the nurse provide?

7 :
A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action?

8 :
A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care? (Select all that apply.)

9 :
A nurse in the nursery is caring for a newborn. The grandmother of the newborn asks if she can take the newborn to the mother's room. Which of the following is an appropriate response by the nurse?

10 :
A nurse is teaching about crib safety with the parent of a newborn. Which of the following statements by the client indicates understanding of the teaching?

1 : A nurse is caring for a client who is 12 hr postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

2 : A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time?

3 : A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

4 : A nurse is caring for a newborn 4 hr after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?

5 : A nurse is assessing a newborn the day after delivery. The nurse notes a raised, bruised area on the left side of the scalp that does not cross the suture line. How should the nurse document this finding?

6 : A nurse is caring for a client who delivered a healthy term newborn via cesarean birth. The client asks the nurse, "Is there a chance that I could deliver my next baby without having a cesarean section?' Which of the following responses should the nurse provide?

7 : A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action?

8 : A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care? (Select all that apply.)

9 : A nurse in the nursery is caring for a newborn. The grandmother of the newborn asks if she can take the newborn to the mother's room. Which of the following is an appropriate response by the nurse?

10 : A nurse is teaching about crib safety with the parent of a newborn. Which of the following statements by the client indicates understanding of the teaching?

1 :
A nurse is caring for a client who is 12 hr postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

2 :
A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time?

3 :
A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

4 :
A nurse is caring for a newborn 4 hr after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?

5 :
A nurse is assessing a newborn the day after delivery. The nurse notes a raised, bruised area on the left side of the scalp that does not cross the suture line. How should the nurse document this finding?

6 :
A nurse is caring for a client who delivered a healthy term newborn via cesarean birth. The client asks the nurse, "Is there a chance that I could deliver my next baby without having a cesarean section?' Which of the following responses should the nurse provide?

7 :
A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action?

8 :
A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care? (Select all that apply.)

9 :
A nurse in the nursery is caring for a newborn. The grandmother of the newborn asks if she can take the newborn to the mother's room. Which of the following is an appropriate response by the nurse?

10 :
A nurse is teaching about crib safety with the parent of a newborn. Which of the following statements by the client indicates understanding of the teaching?