Nokea
A breastfeeding mother calls the obstetrician's office with a complaint of pain in one breast. Upon inspection, a diagnosis of mastitis is made. Which of the following nursing interventions is appropriate?
- A. Advise the woman to apply ice packs to her breasts.
- B. Encourage the woman to breastfeed frequently.
- C. Inform the woman that she should wean immediately.
- D. Direct the woman to notify her pediatrician as soon as possible.
Correct Answer: B
Rationale: Frequent breastfeeding helps clear infection.
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The postpartum nurse is observing a patient holding the baby she delivered less than 24 hours ago. The partner is watching his wife and asking questions about newborn care. The
- A. Report the incident to the social services department.
- B. Advise the parents that the older son needs to be reprimande
- C. No action; this is a normal family adjusting to family change
- D. Report to oncoming staff that the mother is probably not a good disciplinarian.
Correct Answer: C
Rationale: Correct Answer: C - No action; this is a normal family adjusting to family change.
Rationale:
1. It is normal for new parents to have questions and concerns about newborn care.
2. The parents are actively engaged with the newborn and seeking information, indicating a positive adjustment.
3. The mother's behavior with the newborn does not raise any immediate concerns for intervention.
4. Reporting to social services or assuming parenting styles based on limited observation is unwarranted.
Summary:
A: Reporting to social services is unnecessary as there are no signs of neglect or abuse.
B: Reprimanding the older son is unrelated to the situation and inappropriate.
D: Assuming the mother's parenting style based on limited observation is unjustified and unprofessional.
Which symptom would the nurse expect to observe in a postpartum client with a vaginal hematoma?
- A. Pain.
- B. Bleeding.
- C. Warmth.
- D. Redness.
Correct Answer: A
Rationale: Pain is a common symptom of a vaginal hematoma.
A breastfeeding client is being seen in the emergency department with a hard, red, warm nodule in the upper outer quadrant of her left breast. Her vital signs are: T 104.6°F, P 100, R 20, and BP 110/60. She has a recent history of mastitis and is crying in pain. Which of the following nursing diagnoses is highest priority?
- A. Ineffective breastfeeding.
- B. Infection.
- C. Ineffective individual coping.
- D. Pain.
Correct Answer: B
Rationale: Infection is the primary concern.
A client is 10 minutes postpartum from a forceps delivery of a 4,500-gram neonate with a cleft lip. The physician performed a right mediolateral episiotomy during the delivery. The client is at risk for each of the following nursing diagnoses. Which of the diagnoses is highest priority at this time?
- A. Ineffective breastfeeding.
- B. Fluid volume deficit.
- C. Infection.
- D. Pain.
Correct Answer: D
Rationale: Pain management is critical post-episiotomy.
If the rubella vaccine is indicated for a postpartum patient, which instructions should be provided?
- A. No specific instructions
- B. Drinking plenty of fluids to prevent fever
- C. Recommendation to stop breastfeeding for 24 hours after the injection
- D. Explanation of the risks of becoming pregnant within 28 days following injection
Correct Answer: D
Rationale: The correct answer is D because the rubella vaccine contains live virus and poses a risk to the fetus if the patient becomes pregnant within 28 days of receiving the vaccine. Providing instructions about the risks of pregnancy after vaccination is crucial to prevent potential harm to the fetus.
A: Incorrect - Specific instructions are necessary due to the live virus in the vaccine.
B: Incorrect - Drinking fluids does not address the specific risks associated with pregnancy after vaccination.
C: Incorrect - Stopping breastfeeding is not necessary after receiving the rubella vaccine.