Nokea
Several hours after delivery, a new mother expresses ambivalence regarding her infant. How will the nurse promote bonding?
- A. Having the mother feed the infant
- B. Removing the infant from the mother's arms if it cries
- C. Positioning the infant so its head rests on the mother's shoulder
- D. Encouraging the mother to sleep for 4 to 6 hours before interacting with the infant
Correct Answer: A
Rationale: The correct answer is A, having the mother feed the infant. This helps promote bonding through physical closeness, eye contact, and the release of oxytocin. Feeding also fosters a sense of responsibility and nurturing. Choice B may disrupt bonding by creating separation anxiety. Choice C is a comforting position but not as interactive as feeding. Choice D delays bonding and can impact the establishment of a strong maternal-infant relationship.
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A high-risk labor patient progresses from preeclampsia to eclampsia. Aggressive management is instituted, and the fetus is delivered via cesarean birth. Which finding in the immediate postoperative period indicates that the patient is at risk of developing HELLP syndrome?
- A. Platelet count of 50,000/mcL
- B. Liver enzyme levels within normal range
- C. Negative for edema
- D. No evidence of nausea or vomiting
Correct Answer: A
Rationale: The correct answer is A: Platelet count of 50,000/mcL. In HELLP syndrome, there is hemolysis, elevated liver enzymes, and low platelet count. A platelet count of 50,000/mcL indicates thrombocytopenia, a key feature of HELLP syndrome. It signifies ongoing coagulation abnormalities and liver dysfunction.
B: Liver enzyme levels within normal range is incorrect as HELLP syndrome typically presents with elevated liver enzymes.
C: Negative for edema is incorrect as edema is not a defining characteristic of HELLP syndrome.
D: No evidence of nausea or vomiting is incorrect as these symptoms are not specific to HELLP syndrome.
The labor and birth nurse is reviewing the risk factors for placenta previa with a group of nursing students. The nurse determines that the students understood the discussion when they identify which patient being at the highest risk for developing a placenta previa?
- A. Female fetus, Mexican-American, primigravida
- B. Male fetus, Asian-American, previous preterm birth
- C. Male fetus, African-American, previous cesarean birth
- D. Female fetus, European-American, previous spontaneous abortion
Correct Answer: C
Rationale: The correct answer is C: Male fetus, African-American, previous cesarean birth. Placenta previa occurs when the placenta partially or completely covers the cervix. African-American women have a higher incidence of placenta previa. Previous cesarean birth is a risk factor due to possible scarring on the uterine wall, increasing the likelihood of placenta implantation issues. Male fetuses are associated with a higher risk of placenta previa, possibly due to a larger placental size. The other choices do not align with known risk factors for placenta previa, such as the ethnicity, fetal gender, and obstetric history mentioned.
A patient with preeclampsia is admitted complaining of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs indicate
- A. gastrointestinal upset.
- B. effects of magnesium sulfate.
- C. anxiety caused by hospitalization.
- D. worsening disease and impending convulsion.
Correct Answer: D
Rationale: The correct answer is D because the symptoms described (headache, visual changes, epigastric pain) are classic signs of worsening preeclampsia, indicating impending eclampsia with seizures. This requires urgent intervention to prevent serious complications. Option A is incorrect as gastrointestinal upset does not typically present with these specific signs. Option B is incorrect as magnesium sulfate is used to prevent seizures in preeclampsia, not cause the symptoms described. Option C is incorrect as anxiety would not cause the specific symptoms mentioned. In summary, the signs described point towards worsening disease and the likelihood of impending convulsions, necessitating immediate medical attention.
A patient has tested HIV-positive and has now discovered that she is pregnant. Which statement indicates that she understands the risks of this diagnosis?
- A. “I know I will need to have an abortion as soon as possible.”
- B. “Even though my test is positive, my baby might not be affected.”
- C. “My baby is certain to have AIDS and die within the first year of life.”
- D. “This pregnancy will probably decrease the chance that I will develop AIDS.”
Correct Answer: B
Rationale: The correct answer is B because it shows understanding that a positive HIV test in the mother doesn't guarantee transmission to the baby. This reflects knowledge of the possibility of preventing mother-to-child transmission with proper medical care. Option A is incorrect as abortion is not the standard recommendation for HIV-positive pregnant women. Option C is incorrect as not all babies born to HIV-positive mothers will have AIDS or die within the first year. Option D is incorrect as pregnancy does not decrease the mother's chance of developing AIDS.
A patient taking magnesium sulfate has a respiratory rate of 10 breaths per minute. In addition to discontinuing the medication, which action should the nurse take?
- A. Increase the patient's IV fluids.
- B. Administer calcium gluconate.
- C. Vigorously stimulate the patient.
- D. Instruct the patient to take deep breaths.
Correct Answer: B
Rationale: The correct answer is B: Administer calcium gluconate. This is because magnesium sulfate can lead to respiratory depression by inhibiting neuromuscular transmission. Calcium gluconate is the antidote as it competes with magnesium for binding sites, reversing its effects. Increasing IV fluids (A) is not directly related to addressing respiratory depression. Vigorously stimulating the patient (C) can exacerbate respiratory depression. Instructing the patient to take deep breaths (D) may not be effective in addressing respiratory depression caused by magnesium sulfate.