Nokea
A client is preparing to breastfeed her newborn son in the cross-cradle position. Which of the following actions should the woman make?
- A. Place a pillow in her lap.
- B. Position the head of the baby in her elbow.
- C. Put the baby on his back.
- D. Move the breast toward the mouth of the baby.
Correct Answer: A
Rationale: A pillow supports the baby and reduces strain.
You may also like to solve these questions
The nurse includes the addition of ice sitz baths for the postpartum patient. Which assessment finding indicates the treatment has been effective?
- A. No swelling or edema to the perineal area
- B. Patient complains that the sitz bath is too col
- C. Patient reports she took two sitz baths in 12 hours.
- D. Edges of the perineal laceration are well approximate
Correct Answer: A
Rationale: The correct answer is A because the absence of swelling or edema to the perineal area indicates that the ice sitz baths have been effective in reducing inflammation and promoting healing. Swelling and edema are common postpartum, and the use of ice sitz baths can help reduce these symptoms.
Choice B is incorrect because the patient complaining that the sitz bath is too cold does not provide information on the effectiveness of the treatment, only the patient's comfort level.
Choice C is incorrect because the frequency of sitz baths does not necessarily indicate effectiveness. It is more important to assess the outcomes of the treatment rather than the number of baths taken.
Choice D is incorrect because the approximation of perineal laceration edges may be influenced by other factors such as suturing technique, rather than the effectiveness of the ice sitz baths.
The nurse is caring for a postoperative cesarean client. The woman is obese and is an insulin-dependent diabetic. For which of the following complications should the nurse carefully monitor this client?
- A. Failed lactogenesis.
- B. Dysfunctional parenting.
- C. Wound dehiscence.
- D. Projectile vomiting.
Correct Answer: C
Rationale: Obesity and diabetes increase the risk of wound complications.
The nurse notes that a newborn, who is 5 minutes old, exhibits the following characteristics: heart rate 108 bpm, respiratory rate 29 rpm with lusty cry, pink body with bluish hands and feet, some flexion. What does the nurse determine the baby's Apgar score is?
- A. 6
- B. 7
- C. 8
- D. 9
Correct Answer: C
Rationale: Scoring: Heart rate (2), respirations (2), color (1), muscle tone (2), reflex irritability (1). Total = 8.
The mother notes that her baby has a 'bulge' on the back of one side of the head. She calls the nurse into the room to ask what the bulge is. The nurse notes that the bulge covers the right parietal bone but does not cross the suture lines. The nurse explains to the mother that the bulge results from which of the following?
- A. Molding of the baby's skull so that the baby could fit through her pelvis.
- B. Swelling of the tissues of the baby's head from the pressure of her pushing.
- C. The position that the baby took in her pelvis during the last trimester of her pregnancy.
- D. Small blood vessels that broke under the baby's scalp during birth.
Correct Answer: A
Rationale: Molding occurs due to passage through the birth canal.
The postpartum patient who continually repeats the story of her labor, birth, and recovery experiences is performing which of the following tasks?
- A. Making the birth experience “real”
- B. Accepting her response to labor and birth
- C. Providing others with her knowledge of events
- D. Taking hold of the events leading to her labor and birth
Correct Answer: A
Rationale: The correct answer is A: Making the birth experience "real." This choice aligns with the concept of emotional processing and integration in the postpartum period. By continually repeating her birth story, the patient is trying to make sense of and come to terms with her experience, making it feel more "real" to her. This process helps her emotionally process the events and transitions she has gone through during labor and birth.
Choices B, C, and D are incorrect:
B: Accepting her response to labor and birth - This choice focuses more on the patient's emotional response rather than the act of repeating the story.
C: Providing others with her knowledge of events - This choice is more about sharing information rather than the internal emotional processing the patient is likely engaging in.
D: Taking hold of the events leading to her labor and birth - This choice suggests a sense of control over the events, which may not necessarily be the primary motivation behind the patient's behavior.