A nurse is caring for a client who is 2 days postpartum.
The client is a Gravida 4 Para 3 who had a forceps-assisted birth with epidural anesthesia at 40 weeks of gestation. She had a second degree mediolateral perineal laceration with repair, and the placenta was manually extracted.
The estimated blood loss was 600 mL. Complete the diagram by dragging from the choices below to specify what condition the client is experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

Apply ice packs to the perineal area.

Monitor for signs of postpartum seizures.

Monitor for signs of strained perineum.

Administer prescribed medications.

Answer and Explanation

Correct Answer : A,C

A nurse is caring for a client who is 2 days postpartum.
The client is a Gravida 4 Para 3 who had a forceps-assisted birth with epidural anesthesia at 40 weeks of gestation. She had a second degree mediolateral perineal laceration with repair, and the placenta was manually extracted.
The estimated blood loss was 600 mL. Complete the diagram by dragging from the choices below to specify what condition the client is experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

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Correct Answer is C

Explanation

Choice A rationale
The Babinski reflex is a normal reflex in infants that disappears by 12 months of age. It involves fanning out of the toes when the sole of the foot is stroked, and it doesn’t promote latching during breastfeeding.
Choice B rationale
The stepping reflex is a primitive reflex that makes newborns appear to take steps or dance when held upright with their feet touching a solid surface. It doesn’t promote latching during breastfeeding.
Choice C rationale
The rooting reflex helps promote latching during breastfeeding. When the corner of the baby’s mouth is touched, the baby will turn his or her head and open his or her mouth to follow and “root” in the direction of the stroking. This helps the baby find the breast or bottle to start feeding.
Choice D rationale
The Moro reflex, also known as the startle reflex, involves the baby throwing back his or her head, extending out the arms and legs, crying, then pulling the arms and legs back in. It doesn’t promote latching during breastfeeding.

A. “You should place your nipple and some of the areola into her mouth.”. B. “Try to place the nipple, the areola, and some breast tissue beyond the areola into her mouth.”. C. “Your baby’s mouth is rather small so she will only take part of the nipple.”. D. “Babies know instinctively how much of the nipple to take into their mouth.”.

Correct Answer is A

Explanation

Choice A rationale
When breastfeeding, it is recommended that the mother places her nipple and some of the areola into the baby’s mouth. This allows the baby to have a good latch, which is important for effective breastfeeding.
Choice B rationale
While it is important for the baby to take a good portion of the breast into their mouth, suggesting to include some breast tissue beyond the areola might be too much for a newborn’s small mouth.
Choice C rationale
This statement is not entirely accurate. While a newborn’s mouth is small, they should take as much of the nipple and areola into their mouth as possible to ensure effective breastfeeding.
Choice D rationale
While babies have certain instincts, they and their mothers often need guidance and practice to achieve a good latch and effective breastfeeding.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting a client with breastfeeding. The nurse explains that which of the following reflexes will promote the newborn to latch?

Correct Answer is C

Explanation

A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the newborn’s mouth, which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is caring for a client who is experiencing a decrease in the fetal heart rate. Which of the following actions should the nurse take?

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A nurse in a prenatal clinic is caring for a client whose blood pressure is 80/40 mm Hg. The client’s last menstrual period was on May 4, 2023. What would be the estimated due date for the client?

A nurse is caring for a client who is postpartum and is breastfeeding. The client states that she is concerned about dietary precautions since she has a family history of food allergies. The nurse offers which of the following responses?

A nurse is caring for a client who is 12 hours postpartum following a vaginal delivery. Which of the following findings should the nurse expect?

A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take?

A nurse is caring for a client who is at 22 weeks of gestation and has been unable to control her gestational diabetes mellitus with diet and exercise. The nurse should anticipate a prescription from the provider for which of the following medications for the client?

A nurse is caring for a client who is in active labor and notes late decelerations on the fetal monitor. Which of the following is the priority nursing action?