Nokea
A client is 36 hours post-cesarean section. Which of the following assessments would indicate that the client may have a paralytic ileus?
- A. Abdominal striae.
- B. Oliguria.
- C. Omphalocele.
- D. Absent bowel sounds.
Correct Answer: D
Rationale: Absence of bowel sounds suggests ileus.
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Which vaccinations are indicated for the postpartum patient if she does not have immunity? (Select all that apply.)
- A. Pertussis
- B. Rubella
- C. Diphtheria, tetanus (Tdap)
- D. RhoGAM
Correct Answer: A
Rationale: Rationale:
1. Pertussis vaccine is recommended in the postpartum period to protect the newborn from whooping cough.
2. Rubella vaccine is usually given preconception or postpartum if the mother is not immune.
3. Tdap vaccine (Diphtheria, Tetanus, Pertussis) is recommended during pregnancy, not specifically postpartum.
4. RhoGAM is given to Rh-negative mothers to prevent hemolytic disease in the newborn, not for general immunity.
The nursery nurse is careful to wear gloves when admitting neonates into the nursery. Which of the following is the scientific rationale for this action?
- A. Meconium is filled with enteric bacteria.
- B. Amniotic fluid may contain harmful viruses.
- C. The high alkalinity of fetal urine is caustic to the skin.
- D. The baby is high risk for infection and must be protected.
Correct Answer: A
Rationale: Meconium contains enteric bacteria, making it important to use gloves to prevent contamination.
The nurse assesses a 2-day postpartum, breastfeeding client. The nurse notes blood on the mother's breast pad and a crack on the mother's nipple. Which of the following actions should the nurse perform at this time?
- A. Advise the woman to wash the area with soap to prevent mastitis.
- B. Provide the woman with a tube of topical lanolin.
- C. Remind the woman that the baby can become sick if he drinks the blood.
- D. Get the woman an order for a topical anesthetic.
Correct Answer: B
Rationale: Lanolin promotes healing.
Which site should the nurse use to assess the pulse of a baby?
- A. Carotid.
- B. Radial.
- C. Brachial.
- D. Pedal.
Correct Answer: C
Rationale: Brachial pulse is easily accessible in infants.
Which action should the nurse take in order to provide support and encouragement to the new postpartum patient?
- A. Recount how she solved her own problems.
- B. Correct the new mother at every opportunity.
- C. Praise the mother’s early attempts at infant car
- D. Explain to the new mother that everything will be fine
Correct Answer: C
Rationale: The correct answer is C: Praise the mother’s early attempts at infant care. This choice focuses on positive reinforcement, which can boost the new mother's confidence and encourage her in her new role. By acknowledging and praising her efforts, the nurse can help build the mother's self-esteem and foster a supportive environment.
Choices A and D do not directly provide support and encouragement to the new mother. Recounting how the nurse solved her own problems (Choice A) may come off as self-centered and not helpful to the new mother's situation. Explaining that everything will be fine (Choice D) may minimize the new mother's feelings and concerns.
Choice B, correcting the new mother at every opportunity, is not supportive or encouraging. It can undermine the mother's confidence and create a negative dynamic. It is important for the nurse to focus on positive reinforcement and support to help the new mother navigate the challenges of postpartum care.