Nokea
A client has given birth to a baby girl with a visible birth defect. Which of the following maternal responses would lead the nurse to suspect poor mother-infant bonding?
- A. The mother states,"I'm so tired. Please feed the baby in the nursery for me."
- B. The mother states,"Her eyes look like mine, but her chin is her Dad's."
- C. The mother says,"We have decided to name her Sarah after my mother."
- D. The mother says,"I breastfed her. I still need help swaddling her, though."
Correct Answer: A
Rationale: Avoidance of infant care suggests bonding issues.
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A client, who is 2 weeks postpartum, calls her obstetrician's nurse and states that she has had a whitish discharge for 1 week but today she is"bleeding and saturating a pad about every 1/2 hour."Which of the following is an appropriate response by the nurse?
- A. That is normal. You are starting to menstruate again.
- B. You should stay on complete bed rest until the bleeding subsides.
- C. Pushing during a bowel movement may have loosened your stitches.
- D. The physician should see you. Please go to the emergency department.
Correct Answer: D
Rationale: Heavy bleeding postpartum requires immediate medical attention.
The nurse is planning comfort measures to implement for a patient after a vaginal birth. Which measures should the nurse plan to include in the patient’s care plan? (Select all that apply.)
- A. Sitz baths four times a day
- B. Use of only warm water with the sitz baths
- C. Topical anesthetic spray after perineal care
- D. Ice pack to the perineum for the first 24 hours
Correct Answer: A
Rationale: The correct answer is A: Sitz baths four times a day. Sitz baths promote healing, reduce swelling, and provide comfort after a vaginal birth. Warm water helps to soothe the perineal area. Choices B, C, and D are incorrect because using warm water alone may not be as effective as sitz baths, topical anesthetic spray may not be necessary for routine care, and ice packs may not be recommended for the first 24 hours due to the risk of vasoconstriction and decreased blood flow to the area.
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.
The nursery charge nurse is assessing a 1-day-old female on morning rounds. Which of the following findings should be reported to the neonatologist as soon as possible? Select all that apply.
- A. Blood in the diaper.
- B. Grunting during expiration.
- C. Deep red coloring on one side of the body with pale pink on the other side.
- D. Lacy and mottled appearance over the entire chest and abdomen.
Correct Answer: B
Rationale: Grunting indicates respiratory distress, and harlequin coloring suggests vascular compromise.
In which of the following situations should a nurse report a possible deep vein thrombosis (DVT)?
- A. The woman complains of numbness in the toes and heel of one foot.
- B. The woman has cramping pain in a calf that is relieved when the foot is dorsiflexed.
- C. One of the woman's calves is swollen, red, and warm to the touch.
- D. The veins in the ankle of one of the woman's legs are spider-like and purple.
Correct Answer: C
Rationale: Swelling, redness, and warmth are classic signs of DVT.