Nokea
A G1P1 has just experienced a 24-hour labor that included a 3-hour second stage. The woman states to the nurse, "I just can't feed my baby now. All I want to do is sleep." What is the appropriate response from the nurse?
- A. Discuss with the woman that the needs of her infant should come first
- B. Recognize this as a behavior of the taking-hold stage
- C. Record the behavior as ineffective bonding/attachment
- D. Reassure the woman that it is okay for her to rest at this time
Correct Answer: D
Rationale: The correct answer is D: Reassure the woman that it is okay for her to rest at this time.
Rationale:
1. The woman has just undergone a 24-hour labor with a 3-hour second stage, which is physically and emotionally exhausting.
2. It is important for the nurse to prioritize the woman's well-being and allow her to rest to recover.
3. Rest is crucial for the woman's recovery and ability to care for her baby effectively.
4. By reassuring her that it is okay to rest, the nurse promotes self-care and maternal well-being.
Other choices:
A: Discuss with the woman that the needs of her infant should come first - This is not the appropriate response as the woman's well-being should also be considered.
B: Recognize this as a behavior of the taking-hold stage - This is incorrect as the woman's exhaustion is likely due to the physically demanding labor.
C: Record the behavior as ineffective bonding/attachment - This is not appropriate
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The nurse is collecting the urine of a postpartum patient who is passing large clots. For which reason does the nurse examine the large collected clots?
- A. To validate the presence of clotting
- B. To determine the presence of tissue
- C. To obtain an accurate description
- D. To document the number of clots
Correct Answer: B
Rationale: The correct answer is B: To determine the presence of tissue. By examining the large collected clots, the nurse can differentiate between clots and actual tissue, which is crucial for identifying any potential complications postpartum. This step ensures accurate assessment and appropriate intervention if necessary.
Incorrect choices:
A: To validate the presence of clotting - This is not necessary as the presence of large clots already indicates clotting.
C: To obtain an accurate description - While important, the primary purpose of examining large clots in this context is to differentiate tissue from clots.
D: To document the number of clots - While documenting the number of clots is important, it is not the main reason for examining them in this scenario.
The nurse is discussing contraception with a couple before discharge following the birth of a first child. The couple are uncertain about the method but are certain about avoiding pregnancy for at least 2 years. Which method does the nurse recommend?
- A. Emergency contraceptives
- B. Oral estrogen/progesterone pill
- C. Depo-Provera
- D. Natural family planning
Correct Answer: C
Rationale: The correct answer is C: Depo-Provera. The couple wants to avoid pregnancy for at least 2 years. Depo-Provera is a highly effective long-acting reversible contraceptive that only requires an injection every 3 months, providing reliable contraception for an extended period. It does not rely on daily adherence like the oral pill (B) or emergency contraceptives (A). Natural family planning (D) may not be the best choice for a couple wanting to avoid pregnancy with certainty for 2 years due to its reliance on tracking menstrual cycles and abstinence during fertile periods.
The nurse is providing care for a new mother during a follow-up visit 6 weeks after a vaginal delivery. The mother begins to cry and reports difficulty with eating and sleeping. The nurse identifies postpartum blues and cites which reason as the most likely cause?
- A. Fatigue related to a 'fussy' baby
- B. Frustration over physical appearance
- C. Changes in hormonal levels
- D. Stress related to new mother role
Correct Answer: C
Rationale: The correct answer is C: Changes in hormonal levels. Postpartum blues are typically attributed to hormonal fluctuations after childbirth, leading to mood swings and emotional distress. During the postpartum period, the sudden drop in estrogen and progesterone levels can affect a mother's emotional well-being. This can manifest as feelings of sadness, crying spells, difficulty sleeping, and changes in appetite. The other answer choices are incorrect because fatigue related to a 'fussy' baby (A), frustration over physical appearance (B), and stress related to the new mother role (D) do not directly address the physiological changes in hormonal levels that are primarily responsible for postpartum blues.
The nurse on a postpartum unit focuses on how to assist the father in identifying his role with the neonate. Which intervention by the nurse is most helpful?
- A. Encourage the couple to identify mutual expectations of the fathering role.
- B. Critique the father's methods of providing physical care for the neonate.
- C. Provide written materials about the physical and emotional role of a father.
- D. Observe for a competitive attitude between the parents about providing baby care.
Correct Answer: A
Rationale: The correct answer is A because it promotes open communication and mutual understanding between the couple. By encouraging the couple to identify mutual expectations of the fathering role, the nurse helps establish a supportive environment for the father to understand his role with the neonate. This intervention fosters collaboration and shared responsibility, which are crucial for a healthy parent-child relationship.
Incorrect choices:
B: Critiquing the father's methods can be discouraging and may create tension between the parents.
C: Providing written materials is informative but may not address the unique dynamics of the couple's relationship.
D: Observing for a competitive attitude does not actively involve the nurse in facilitating the father's understanding of his role.
The nurse is preparing to do a morning assessment on a 24-hour postpartum patient. Which nursing intervention is most appropriate initially?
- A. Massage the fundus until it is firm.
- B. Instruct the mother to void prior to the assessment.
- C. Assess the lochia flow while massaging the fundus.
- D. Lower the head of the bed and have the mother lie flat.
Correct Answer: B
Rationale: The correct initial nursing intervention is to instruct the mother to void prior to the assessment (choice B). This is important as a full bladder can interfere with the accuracy of the fundal assessment. By ensuring the mother voids first, the nurse can accurately assess the fundus for any signs of excessive bleeding or abnormalities. This step is crucial in monitoring the postpartum patient's well-being.
Choice A is incorrect as massaging the fundus should come after assessing the lochia flow to prevent potential complications. Choice C is also incorrect as assessing the lochia flow should occur before massaging the fundus. Choice D is incorrect as lowering the head of the bed and having the mother lie flat is not necessary for a postpartum assessment.