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A breastfeeding woman has been diagnosed with retained placental fragments 4 days postdelivery. Which of the following breastfeeding complications would the nurse expect to see?
- A. Engorgement.
- B. Mastitis.
- C. Blocked milk duct.
- D. Low milk supply.
Correct Answer: B
Rationale: Retained fragments increase infection risk.
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To promote bonding and attachment immediately after birth, which action should the nurse take?
- A. Assist the mother in feeding her baby.
- B. Allow the mother quiet time with her infant.
- C. Teach the mother about the concepts of bonding and attachment.
- D. Assist the mother in assuming an en face position with her newborn.
Correct Answer: D
Rationale: The correct answer is D because assuming an en face position (face-to-face) with the newborn promotes bonding and attachment by facilitating eye contact, skin-to-skin contact, and mutual recognition between the mother and baby. This physical closeness immediately after birth helps establish a strong emotional connection.
A: Assisting with feeding is important but does not specifically address bonding and attachment immediately after birth.
B: Allowing quiet time is beneficial but may not actively promote bonding and attachment.
C: Teaching about bonding and attachment is valuable but does not directly facilitate the immediate connection between mother and baby.
Which measure is optimal in order to prevent abdominal distention following a cesarean birth?
- A. Rectal suppositories
- B. Carbonated beverages
- C. Early and frequent ambulation
- D. Tightening and relaxing abdominal muscles
Correct Answer: C
Rationale: The correct answer is C: Early and frequent ambulation. This measure is optimal to prevent abdominal distention following a cesarean birth because it helps promote bowel motility and gas expulsion. Ambulation stimulates peristalsis, preventing gas accumulation and reducing the risk of distention. Rectal suppositories (A) may help with constipation but do not address the root cause of distention. Carbonated beverages (B) can exacerbate bloating and gas production. Tightening and relaxing abdominal muscles (D) may provide some relief but are not as effective as promoting ambulation for preventing abdominal distention.
A client is being discharged on Coumadin (warfarin) post-pulmonary embolism after a cesarean delivery. Which of the following laboratory values indicates that the medication is effective?
- A. PT (prothrombin time): 12 sec (normal is 10-13 seconds).
- B. INR (international normalized ratio): 2.5 (normal is 1.0-1.4).
- C. Hematocrit 55%.
- D. Hemoglobin 10 g/dL.
Correct Answer: B
Rationale: An INR of 2.5 indicates therapeutic anticoagulation.
A woman who wishes to breastfeed advises the nurse that she has had breast augmentation surgery. Which of the following responses by the nurse is appropriate?
- A. Breast implants often contaminate the milk with toxins.
- B. The glandular tissue of women who need implants is often deficient.
- C. Babies often have difficulty latching to the nipples of women with breast implants.
- D. Women who have implants are often able exclusively to breastfeed.
Correct Answer: D
Rationale: Implants do not preclude breastfeeding.
The nurse is caring for a postpartum patient who delivered by the vaginal route 12 hours ago. Which assessment finding should the nurse report to the health care provider?
- A. Pulse rate of 50
- B. Temperature of 38C (100.4F)
- C. Firm fundus, but excessive lochia
- D. Lightheaded when moving from a lying to standing position
Correct Answer: A
Rationale: Correct Answer: A - Pulse rate of 50
Rationale:
1. A normal postpartum pulse rate is 60-100 bpm.
2. A pulse rate of 50 is below normal range, indicating potential bradycardia.
3. Bradycardia can be a sign of postpartum hemorrhage or other complications.
4. Reporting this finding promptly can help in early intervention.
Summary:
B: A temperature of 38C (100.4F) could indicate infection but is within normal postpartum range.
C: A firm fundus with excessive lochia may indicate uterine atony, but is not as urgent as bradycardia.
D: Feeling lightheaded when changing positions is common postpartum but not as concerning as a low pulse rate.