Nokea
A couple, accompanied by their 5-year-old daughter, have been notified that their 32-week-gestation fetus is dead. The father is yelling at the staff. The mother is crying uncontrollably. The 5-year-old is banging the head of her doll on the floor. Which of the following nursing actions is appropriate at this time?
- A. Tell the father that his behavior is inappropriate.
- B. Sit with the family and quietly communicate sorrow at their loss.
- C. Help the couple to understand that their daughter is acting inappropriately.
- D. Encourage the couple to send their daughter to her grandparents.
Correct Answer: B
Rationale: Supportive presence is key.
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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.
A postpartum woman has been diagnosed with postpartum psychosis. Which of the following signs/symptoms would the client exhibit?
- A. Hallucinations.
- B. Polyphagia.
- C. Induced vomiting.
- D. Weepy sadness.
Correct Answer: A
Rationale: Hallucinations are characteristic of psychosis.
The nurse is caring for a birth mother who is relinquishing her newborn. What intervention is appropriate for the nurse?
- A. Use words like “giving away your child” or “giving up for adoption.”
- B. Tell the person not to hold the baby.
- C. Ask the person why she is giving up her baby.
- D. Ask about the patient’s expectations for having newborn photos or video.
Correct Answer: D
Rationale: The correct answer is D because asking about the patient's expectations for newborn photos or video shows empathy and support for the mother's emotional needs during this difficult time. It allows the nurse to provide personalized care and helps the mother create lasting memories.
A: Using phrases like "giving away your child" is insensitive and can be hurtful to the mother.
B: Discouraging the mother from holding the baby can be emotionally damaging and is not supportive.
C: Asking why she is giving up her baby can be intrusive and may not be helpful at this moment.
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.
Four pregnant women advise the nurse that they wish to breastfeed their babies. Which of the mothers should be advised to bottle feed her child?
- A. The woman with a neoplasm requiring chemotherapy.
- B. The woman with cholecystitis requiring surgery.
- C. The woman with a concussion.
- D. The woman with thrombosis.
Correct Answer: A
Rationale: Chemotherapy agents can harm the baby through breast milk.