Nokea
A client, G1 P0000, is PP1 from a normal spontaneous delivery of a baby boy, Apgar 5/6. Because the client exhibited addictive behaviors, a toxicology assessment was performed; the results were positive for alcohol and cocaine. Which of the following interventions is appropriate for the nurse to perform for this postpartum client?
- A. Strongly advise the client to breastfeed her baby.
- B. Perform hourly incentive spirometer respiratory assessments.
- C. Suggest that the nursery nurse feed the baby in the nursery.
- D. Provide the client with supervised instruction on baby-care skills.
Correct Answer: D
Rationale: Supervised instruction ensures safe infant care.
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A client has been receiving magnesium sulfate for severe preeclampsia for 12 hours. Her reflexes are 0 and her respiratory rate is 10. Which of the following situations could be a precipitating factor in these findings?
- A. Apical heart rate 104 bpm.
- B. Urinary output 240 mL/12 hr.
- C. Blood pressure 160/120.
- D. Temperature 100°F.
Correct Answer: B
Rationale: Decreased urinary output can lead to magnesium toxicity.
A serum electrolyte report for a client, 1 day post-cesarean delivery for eclampsia, has just been received by the nurse. The client is receiving 5% dextrose in 1/2 normal saline IV at 125 mL/hr and magnesium sulfate 2 G/hr IV via infusion pump. Which of the following values should the nurse report to the surgeon?
- A. Magnesium 7 mg/dL.
- B. Sodium 136 mg/dL.
- C. Potassium 3.0 mg/dL.
- D. Calcium 9 mg/dL.
Correct Answer: A
Rationale: Elevated magnesium levels indicate toxicity.
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.
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.
Postpartum persons who lack attachment with their newborn exhibit what behavior?
- A. intense eye contact
- B. avoid holding the newborn
- C. cuddling
- D. exploring the newborn
Correct Answer: B
Rationale: The correct answer is B because avoiding holding the newborn is a sign of lack of attachment in postpartum persons. This behavior indicates a lack of desire or ability to bond with the newborn, which is crucial for healthy emotional development. Intense eye contact (choice A) and cuddling (choice C) are typically associated with bonding behaviors. Exploring the newborn (choice D) can also be a positive behavior showing interest. However, the key indicator of attachment issues is the avoidance of holding the newborn, making choice B the correct answer.