Question

Which of the following post-partum affective disorders exhibits mild depressive symptoms of anxiety. irritability, mood swings? This disorder peaks postpartum days 4-5 and usually resolvepy day 10,

Answer 1

Correct Answers:

Post-partum baby blues

Rationale :

🌸The postpartum baby blues is a mild affective disorder that occurs in most women during the first week after delivery.

🌸It typically presents with mild depressive symptoms such as anxiety, irritability, mood swings, tearfulness, and insomnia.

🌸The onset usually peaks on postpartum days 4–5 when hormonal changes, physical exhaustion, and adjustment to motherhood are at their height.

🌸Symptoms are self-limiting and usually resolve by day 10, distinguishing it from postpartum depression, which is more severe and prolonged.

🌸Education and reassurance are the main interventions, as this condition generally does not require medical treatment.

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Answer 2

Correct Answers:

Methylergonovine 0.2 mg 1M now.

Rationale :

⚠️Methylergonovine (Methergine) is contraindicated in clients with hypertension because it causes vasoconstriction, which can further elevate blood pressure and increase the risk of stroke or seizure.

⚠️The client’s blood pressure of 146/94 mm Hg indicates elevated readings, making this medication unsafe.

⚠️While oxytocin and other uterotonics are commonly used to manage heavy bleeding, methylergonovine must be avoided in this situation.

⚠️Administering it without clarification could place the client at significant cardiovascular risk.

⚠️The nurse must always evaluate vital signs and contraindications before implementing postpartum hemorrhage interventions.

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Answer 3

Correct Answers:

Apply an ice pack to the affected area.

Rationale :

❄️Cold therapy such as an ice pack is the appropriate intervention for perineal pain and swelling within the first 24 hours after birth.

❄️Ice reduces edema, provides numbing relief, and minimizes discomfort from an episiotomy or laceration.

❄️This intervention is safe, non-invasive, and effective in the early postpartum period before switching to heat therapy.

❄️It also prevents further tissue trauma and enhances comfort, encouraging early mobility and maternal-infant bonding.

❄️Nursing care must focus on pain relief and comfort measures to promote healing and recovery.

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Answer 4

Correct Answers:

12-24 hours

Rationale :

🍼A healthy newborn should pass meconium within the first 12–24 hours of life.

🍼Meconium is composed of amniotic fluid, bile, epithelial cells, and intestinal secretions, giving it a green-black tarry appearance.

🍼Passage of meconium indicates a patent gastrointestinal tract and normal peristalsis.

🍼Delay beyond 24 hours may indicate intestinal obstruction, Hirschsprung’s disease, or meconium ileus.

🍼Early nursing assessments focus on monitoring stool patterns to ensure proper GI adaptation to extrauterine life.

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Answer 5

Correct Answers:

Variable decelerations

Rationale :

🔻Variable decelerations on the fetal monitor are associated with umbilical cord compression.

🔻These appear as abrupt decreases in fetal heart rate of varying duration and intensity, not tied to contractions.

🔻Umbilical cord compression compromises oxygen and blood flow, posing risks of fetal hypoxia and distress.

🔻Nursing interventions may include repositioning the mother, administering oxygen, or amnioinfusion if ordered.

🔻Prompt recognition and response are essential to prevent adverse neonatal outcomes.

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Answer 6

Correct Answers:

Suction the mouth with a bulb syringe.

Rationale :

👶The priority action when a newborn has secretions bubbling from the nose and mouth is to suction the mouth before the nose.

👶This prevents aspiration and ensures the airway remains patent for adequate breathing.

👶Suctioning the mouth first avoids stimulating a gasp reflex that could pull secretions deeper into the airway if the nose is suctioned first.

👶Maintaining a clear airway is the top priority in immediate newborn care and supports effective oxygenation.

👶This intervention reduces the risk of respiratory distress and aspiration pneumonia.

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Answer 7

Correct Answers:

Suction the mouth with a bulb syringe.

Rationale :

👶The priority action when a newborn has secretions bubbling from the nose and mouth is to suction the mouth before the nose.

👶This prevents aspiration and ensures the airway remains patent for adequate breathing.

👶Suctioning the mouth first avoids stimulating a gasp reflex that could pull secretions deeper into the airway if the nose is suctioned first.

👶Maintaining a clear airway is the top priority in immediate newborn care and supports effective oxygenation.

👶This intervention reduces the risk of respiratory distress and aspiration pneumonia.

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Answer 8

Correct Answers:

Elevate her leg.

Rationale :

🦵Pain and redness in the calf postpartum suggest deep vein thrombosis (DVT), a potentially serious complication.

🦵Elevating the leg promotes venous return, reduces swelling, and alleviates discomfort.

🦵Other measures such as bed rest and anticoagulant therapy will be prescribed, but elevation is an immediate safe nursing suggestion.

🦵Massage and cold compresses are contraindicated, as they can dislodge a clot, leading to pulmonary embolism.

🦵Education on prompt evaluation and positioning is critical to reduce complications.

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Answer 9

Correct Answers:

Vastus lateralis

Rationale :

💉The vastus lateralis muscle of the thigh is the preferred site for newborn IM injections, including vitamin K.

💉This muscle is well developed at birth, has few major nerves and blood vessels, and allows for safe absorption.

💉Other sites such as the deltoid or gluteal muscles are not recommended due to underdevelopment and higher risk of injury.

💉Administering vitamin K prevents hemorrhagic disease of the newborn by supporting clotting factor synthesis.

💉Proper injection technique and site selection are essential for safe newborn medication administration.

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Answer 10

Correct Answers:

Insert a gloved hand into the vagina to relieve pressure on the cord.

Rationale :

🚨In umbilical cord prolapse, the first action is to insert a gloved hand into the vagina to lift the presenting part off the cord.

🚨This maneuver maintains blood flow and oxygenation to the fetus until delivery can occur.

🚨Cord compression can cause severe fetal hypoxia and bradycardia, making this a true emergency.

🚨After relieving pressure, the nurse should prepare for an immediate delivery and implement other supportive measures.

🚨Quick recognition and intervention can mean the difference between fetal survival and compromise.

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Custom RN~Maternity Assessment 3, Taylor College FL-ADN

No.

1 :
Which of the following post-partum affective disorders exhibits mild depressive symptoms of anxiety. irritability, mood swings? This disorder peaks postpartum days 4-5 and usually resolvepy day 10,

3 :
A nurse is caring for a client who reports unrelieved episiotomy pain 8 hr following a vaginal birth. Which of the following actions should the nurse take?

4 :
The newborn's first stool is called meconium. It is composed of amniotic fluid, shed mucous cells, intestinal secretions, and blood. It is green-black in color and tarry consistency. When should the first stool (meconium) passed after birth?

5 :
A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?

6 :
A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn's nose and mouth. Which of the following actions is the nurse's priority?

7 :
A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn's nose and mouth. Which of the following actions is the nurse's priority?

8 :
A nurse is caring for a client who is 7 days postpartum and calls the clinic to report pain and redness of her left calf. Besides seeing her provider, which of the following interventions should the nurse suggest?

9 :
A nurse is preparing to administer vitamin K by 1M injection to a newborn. The nurse should administer the medication into which of the following muscles?

10 :
A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?

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Custom RN~Maternity Assessment 3, Taylor College FL-ADN

No.

1 : Which of the following post-partum affective disorders exhibits mild depressive symptoms of anxiety. irritability, mood swings? This disorder peaks postpartum days 4-5 and usually resolvepy day 10,

3 : A nurse is caring for a client who reports unrelieved episiotomy pain 8 hr following a vaginal birth. Which of the following actions should the nurse take?

4 : The newborn's first stool is called meconium. It is composed of amniotic fluid, shed mucous cells, intestinal secretions, and blood. It is green-black in color and tarry consistency. When should the first stool (meconium) passed after birth?

5 : A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?

6 : A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn's nose and mouth. Which of the following actions is the nurse's priority?

7 : A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn's nose and mouth. Which of the following actions is the nurse's priority?

8 : A nurse is caring for a client who is 7 days postpartum and calls the clinic to report pain and redness of her left calf. Besides seeing her provider, which of the following interventions should the nurse suggest?

9 : A nurse is preparing to administer vitamin K by 1M injection to a newborn. The nurse should administer the medication into which of the following muscles?

10 : A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?

1 :
Which of the following post-partum affective disorders exhibits mild depressive symptoms of anxiety. irritability, mood swings? This disorder peaks postpartum days 4-5 and usually resolvepy day 10,

3 :
A nurse is caring for a client who reports unrelieved episiotomy pain 8 hr following a vaginal birth. Which of the following actions should the nurse take?

4 :
The newborn's first stool is called meconium. It is composed of amniotic fluid, shed mucous cells, intestinal secretions, and blood. It is green-black in color and tarry consistency. When should the first stool (meconium) passed after birth?

5 :
A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?

6 :
A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn's nose and mouth. Which of the following actions is the nurse's priority?

7 :
A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn's nose and mouth. Which of the following actions is the nurse's priority?

8 :
A nurse is caring for a client who is 7 days postpartum and calls the clinic to report pain and redness of her left calf. Besides seeing her provider, which of the following interventions should the nurse suggest?

9 :
A nurse is preparing to administer vitamin K by 1M injection to a newborn. The nurse should administer the medication into which of the following muscles?

10 :
A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?