Nokea
A client is receiving a blood transfusion after the delivery of a placenta accreta and hysterectomy. Which of the following complaints by the client would warrant immediately discontinuing the infusion?
- A. My lower back hurts all of a sudden.
- B. My hands feel so cold.
- C. I feel like my heart is beating fast.
- D. I feel like I need to have a bowel movement.
Correct Answer: A
Rationale: Back pain can indicate a hemolytic reaction.
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A woman has just had a low forceps delivery. For which of the following should the nurse assess the woman during the immediate postpartum period?
- A. Infection.
- B. Bloody urine.
- C. Heavy lochia.
- D. Rectal abrasions.
Correct Answer: C
Rationale: Heavy lochia indicates potential hemorrhage.
Research has shown what intervention increases involvement of the adolescent partner postpartum?
- A. involvement of the partner during the prenatal period
- B. involvement of parents in decision making
- C. restricting people in the labor room
- D. providing newborn care in the nursery
Correct Answer: A
Rationale: The correct answer is A: involvement of the partner during the prenatal period. This intervention increases the involvement of the adolescent partner postpartum by fostering a sense of responsibility, connection, and support early on in the pregnancy. By actively engaging the partner in prenatal care and decision-making processes, they are more likely to feel invested in the pregnancy and the well-being of the newborn. This involvement also promotes better communication and shared responsibilities between the partners, leading to a smoother transition into parenthood.
Summary of why other choices are incorrect:
B: Involvement of parents in decision making may be beneficial but does not directly address the involvement of the adolescent partner postpartum.
C: Restricting people in the labor room does not promote partner involvement postpartum and may hinder support networks.
D: Providing newborn care in the nursery may be helpful for short-term respite but does not enhance the involvement of the partner postpartum.
The nurse assesses the breasts. What is a warning sign?
- A. colostrum expressed
- B. nipple everted
- C. redness, pain, and heat
- D. filling with milk
Correct Answer: C
Rationale: The correct answer is C because redness, pain, and heat are warning signs of a possible breast infection or inflammation, such as mastitis. This indicates an abnormality that requires further assessment and intervention.
A: Colostrum expressed is a normal occurrence during pregnancy or after delivery and is not a warning sign.
B: Nipple everted is also a normal anatomical variation and not a warning sign.
D: Filling with milk is expected during lactation and not necessarily indicative of a problem.
The nurse observes a patient on her first postpartum day sitting in bed while her newborn lies awake in the bassinet. Which action is most appropriate for the nurse to take at this time?
- A. Hand the baby to the woman.
- B. Explain “taking-in” to the woman.
- C. Offer to hand the baby to the woman.
- D. No action, because this situation is perfectly acceptabl
Correct Answer: B
Rationale: The correct answer is B: Explain "taking-in" to the woman. This action allows the nurse to educate the woman on the normal postpartum adjustment period. By explaining "taking-in," the nurse helps the woman understand her current need for rest and reflection without feeling guilty about not immediately attending to her newborn. This approach promotes bonding by reducing anxiety and enhancing the mother's confidence in her abilities.
Summary of other choices:
A: Hand the baby to the woman - This choice may not address the woman's emotional needs and understanding of her current state.
C: Offer to hand the baby to the woman - While offering is a good gesture, it may not address the underlying need for education and reassurance.
D: No action, because this situation is perfectly acceptable - Ignoring the opportunity to provide guidance and support may lead to confusion and insecurity for the woman.
A postpartum patient calls the clinic and reports to the nurse feelings of fatigue, tearfulness, and anxiety. What is the nurse’s most appropriate response at this time?
- A. “When did these symptoms begin?”
- B. “Sounds like normal postpartum depression.”
- C. “Are you having trouble getting enough sleep?”
- D. “Are you able to get out of bed and provide care for your baby?”
Correct Answer: A
Rationale: The correct answer is A: "When did these symptoms begin?" The nurse's response should address the patient's concerns and gather more information to assess the situation accurately. By asking when the symptoms began, the nurse can determine the duration and severity of the symptoms, enabling appropriate intervention.
Choice B is incorrect because assuming the symptoms are due to "normal postpartum depression" without further assessment is premature and may overlook other potential causes. Choice C focuses solely on sleep and may not address the underlying issues causing the patient's symptoms. Choice D assumes the patient's ability to provide care for the baby without first addressing the patient's emotional well-being.