Nokea
The nurse is aware that some parenting skills are acquired through the process of intentional learning. Which activity does the nurse associate with intentional learning?
- A. The couple observes other individuals who are mothers and fathers.
- B. The couple attends hospital classes addressing newborn and infant care.
- C. The couple discusses with each other how they were parented.
- D. The couple watches media containing parenting roles.
Correct Answer: B
Rationale: The correct answer is B because attending hospital classes on newborn and infant care involves intentional learning by actively seeking out information and skills related to parenting. The couple is proactively engaging in a structured learning environment to acquire knowledge and techniques essential for parenting.
A: Observing other individuals who are parents may provide some insight, but it is more passive and not as structured as intentional learning.
C: Discussing how they were parented is reflective, but it does not necessarily involve seeking out new information or skills actively.
D: Watching media containing parenting roles can provide some information passively, but it may not be as reliable or comprehensive as attending formal classes.
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Which nursing care goal is the highest priority for a woman who had a vaginal delivery 3 hours earlier?
- A. The client will wear a well-supported bra.
- B. The client will eat 100% of her meals.
- C. The client will have a moderate lochia flow.
- D. The client will ambulate to the bathroom.
Correct Answer: C
Rationale: The correct answer is C because monitoring lochia flow is crucial post-vaginal delivery to assess for excessive bleeding, which could indicate postpartum hemorrhage. This goal takes precedence over other options as it pertains to the client's immediate health and well-being. A: Wearing a bra does not address any urgent postpartum concerns. B: Eating meals is important but does not take priority over assessing for hemorrhage. D: Ambulation is beneficial but not as critical as monitoring lochia flow for potential complications.
A nurse is taking care of a G2P2 woman with a third-degree perineal tear during the fourth stage of labor. The nurse should include which intervention in the plan of care during her 12-hour shift?
- A. Assess vital signs every 4 hours.
- B. Keep patient NPO for first 12 hours.
- C. Catheterize patient prior to first ambulation.
- D. Prepare ice pack for application to perineal area.
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Ice pack application helps reduce swelling and pain in the perineal area post-tear.
2. Ice packs can promote vasoconstriction, reducing bleeding risk.
3. Ice packs are non-invasive and can offer immediate relief.
Summary:
A: Assessing vital signs every 4 hours is important but not directly related to perineal tear care.
B: Keeping the patient NPO for 12 hours is unnecessary and may lead to dehydration.
C: Catheterization is not typically required for perineal tear care unless there are specific indications.
The nurse on a postpartum unit is acutely aware that cultural influences impact the patient's process of 'becoming a mother.' For which isn't a cultural influence does the nurse assess?
- A. What amount of time the mother spends in each phase
- B. Differences in the mother's expectation related to ability to rest
- C. How the mother physically recovers from labor and delivery
- D. Mother's involvement in decision making for the first few months
Correct Answer: C
Rationale: Rationale: The correct answer is C because physical recovery from labor and delivery is a biological process, not solely influenced by culture. Other choices (A, B, D) relate to cultural factors affecting the mother's transition to motherhood, such as rituals, beliefs, and social expectations. Cultural influence can affect the time spent in each phase, expectations related to rest, and decision-making processes. It is crucial for the nurse to assess these cultural influences to provide culturally competent care.
The nurse is performing a uterus assessment on a patient who is 20 hours postpartum. The nurse finds the fundus of the uterus to be soft and boggy. In addition, the uterus is displaced to the left and moderate bleeding is noted. If the uterus does respond to uterine massage, which actions does the nurse implement?
- A. Assist the patient to the bathroom to void.
- B. Reassess to determine response to treatment.
- C. Administer oxytocin as prescribed.
- D. Place an emergency call to the HCP.
Correct Answer: D
Rationale: The correct answer is D: Place an emergency call to the HCP. In this scenario, the findings of a soft, boggy fundus, left displacement, and moderate bleeding indicate uterine atony, a common cause of postpartum hemorrhage. If uterine massage doesn't improve the situation, immediate intervention is crucial. Calling the healthcare provider allows for rapid assessment and potential interventions like administering uterotonics or other necessary treatments to address the postpartum hemorrhage promptly. Choices A (assisting the patient to void) and C (administering oxytocin) are important interventions but not the priority in this critical situation. Choice B (reassessing) can delay necessary interventions for managing postpartum hemorrhage.
Which nursing care goal is the highest priority for a woman who had a vaginal delivery 3 hours earlier?
- A. The client will wear a well-supported bra.
- B. The client will eat 100% of her meals.
- C. The client will have a moderate lochia flow.
- D. The client will ambulate to the bathroom.
Correct Answer: C
Rationale: The correct answer is C: The client will have a moderate lochia flow. This is the highest priority because excessive or scant lochia flow can indicate postpartum hemorrhage or retained placental fragments, which are serious postpartum complications. Ensuring a moderate lochia flow is essential for assessing the woman's postpartum recovery and preventing potential complications.
Choice A (The client will wear a well-supported bra) is not a priority in the immediate postpartum period and does not directly impact the woman's physical health.
Choice B (The client will eat 100% of her meals) is important for the woman's nutrition and recovery but is not as critical as monitoring the lochia flow to prevent complications like hemorrhage.
Choice D (The client will ambulate to the bathroom) is important for preventing complications like blood clots and promoting circulation, but monitoring the lochia flow takes precedence in the immediate postpartum period to assess for any signs of hemorrhage or infection.