A breastfeeding mother who is 2 weeks postpartum is informed by her pediatrician that her 4-year-old has chickenpox (varicella). The mother calls the nursery nurse because she is concerned about having the baby in contact with the sick sibling. The mother had chickenpox as a child. Which of the following responses by the nurse is appropriate?
- A. The baby received passive immunity through the placenta
- B. plus the breast milk will also be protective.
- C. The baby should stay with relatives until the ill sibling recovers from the episode of chickenpox.
- D. Chickenpox is transmitted by contact route so careful hand washing should prevent transmission.
Correct Answer: A
Rationale: Maternal antibodies protect the baby, and breast milk enhances immunity.
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Which of the following behaviors would be applicable to a nursing diagnosis of Risk for Impaired Parenting?
- A. En face behavior is observed between father and infant.
- B. Mother relates that she feels exhilarated postbirth.
- C. Mother states that she feels excessive fatigue as a result of the childbirth
- D. Father displays finger tipping behavior toward infant.
Correct Answer: C
Rationale: The correct answer is C because excessive fatigue post-childbirth can indicate a risk for impaired parenting due to the physical and emotional toll it takes on the mother's ability to care for her infant. This aligns with the defining characteristics of Risk for Impaired Parenting.
A: En face behavior is a positive interaction between parent and infant, not indicative of impaired parenting.
B: Feeling exhilarated post-birth is a normal emotional response and does not necessarily indicate impaired parenting.
D: Finger tipping behavior towards infant is vague and does not specifically relate to impaired parenting.
A woman who wishes to breastfeed advises the nurse that she had a breast reduction one year earlier. Which of the following responses by the nurse is appropriate?
- A. Advise the woman that unfortunately she will be unable to breastfeed.
- B. Examine the woman's breasts to see where the incision was placed.
- C. Monitor the baby's daily weights for excessive weight loss.
- D. Inform the woman that reduction surgery rarely affects milk transfer.
Correct Answer: C
Rationale: Weight monitoring ensures adequate milk transfer.
A new father calls the nurse’s station stating that his wife, who delivered last week, is happy one minute and crying the next. He states, “She was never like this before the baby was born.” How should the nurse best respond?
- A. Reassure him that this behavior is normal.
- B. Advise him to get immediate psychological help for her.
- C. Tell him to ignore the mood swings because they will go away.
- D. Instruct him in the signs, symptoms, and duration of postpartum blues.
Correct Answer: A
Rationale: The correct answer is A. The nurse should reassure the father that his wife's behavior of mood swings is normal after childbirth due to hormonal changes and adjustment to new responsibilities. This response validates the father's concerns, provides education on common postpartum experiences, and offers support.
Incorrect choices:
B: Immediate psychological help is not warranted for typical postpartum mood swings.
C: Ignoring the mood swings can lead to misunderstandings and lack of support for the mother.
D: Instructing on postpartum blues is more clinical and may not address the father's immediate concerns.
A mother calls the nurse to her room because 'My baby's eyes are bleeding.' The nurse notes bright red hemorrhages in the sclerae of both of the baby's eyes. Which of the following actions by the nurse is appropriate at this time?
- A. Notify the pediatrician immediately and report the finding.
- B. Notify the social worker about the probable maternal abuse.
- C. Reassure the mother that the trauma resulted from pressure changes at birth and the hemorrhages will slowly disappear.
- D. Obtain an ophthalmoscope from the nursery to evaluate the red reflex and condition of the retina in each eye.
Correct Answer: C
Rationale: Subconjunctival hemorrhages are common and resolve spontaneously.
The nurse evaluates a postpartum couplet for parent-infant attachment. What finding would be concerning?
- A. The postpartum person is sleepy.
- B. Parents are both caring for the infant.
- C. The parent is disinterested in the infant.
- D. The family is involved.
Correct Answer: C
Rationale: The correct answer is C because parent-infant attachment involves emotional bonding and responsiveness. If a parent is disinterested, it may indicate a lack of bonding and potential attachment issues. Choice A is not concerning as sleepiness is common postpartum. Choice B is positive as both parents caring for the infant contributes to attachment. Choice D is also positive as family involvement can support attachment.