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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 because after a long labor, it is crucial for the woman to rest and recover. By reassuring her that it is okay to rest, the nurse acknowledges the importance of self-care for the mother's well-being, which ultimately benefits the baby. This response promotes maternal mental health and physical recovery, which are essential for successful breastfeeding and bonding with the baby.
Choice A is incorrect as it may create unnecessary guilt and pressure on the mother. Choice B is incorrect as the behavior described does not specifically align with the taking-hold stage. Choice C is incorrect as labeling the behavior as ineffective bonding/attachment without further assessment could be harmful and premature.
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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 identify if there is any tissue present, which could indicate a potential complication like retained placental tissue. This is crucial for the patient's health and further management.
Incorrect choices:
A: To validate the presence of clotting - This is not the primary reason for examining the clots in this scenario.
C: To obtain an accurate description - While important, the main focus is on identifying tissue presence.
D: To document the number of clots - The primary concern is not the number of clots but rather the presence of tissue.
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: Step 1: The nurse examines the large collected clots to determine the presence of tissue.
Step 2: Presence of tissue may indicate retained placental fragments, which can lead to postpartum hemorrhage.
Step 3: Identifying tissue is crucial for proper management and prevention of complications.
Step 4: Validating clotting (Choice A) is important but not the primary reason for examining the clots.
Step 5: Obtaining an accurate description (Choice C) and documenting the number of clots (Choice D) are less critical compared to identifying tissue.
The nurse is educating the postpartum client on lactation suppression. Which instructions to the client regarding lactation suppression should be included? Select all that apply.
- A. "Take warm showers twice a day."
- B. "Pump each breast three times a day."
- C. "Apply a heating pad to each breast."
- D. "Wear a well-fitting bra for the first 5 to 6 days."
Correct Answer: D
Rationale: Rationale: Option D is correct because wearing a well-fitting bra provides support and helps reduce stimulation to the breasts, aiding in lactation suppression. Warm showers, pumping, and applying heating pads can all increase milk production, which is counterproductive to lactation suppression. Therefore, options A, B, and C are incorrect.
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 fosters open communication between the couple, allowing them to discuss and align their expectations regarding the father's role with the newborn. This intervention promotes mutual understanding and collaboration, which are crucial for successful parenting.
Choice B is incorrect as critiquing the father's methods may be perceived as judgmental and could hinder his confidence in caring for the baby.
Choice C is also incorrect because providing written materials alone may not effectively address the unique needs and dynamics of the couple's relationship and may not encourage active involvement from the father.
Choice D is incorrect as it focuses on potential conflicts between the parents rather than facilitating a supportive and cooperative environment for the father to establish his role with the neonate.
The nurse is educating the postpartum client on lactation suppression. Which instructions to the client regarding lactation suppression should be included? Select all that apply.
- A. "Take warm showers twice a day."
- B. "Pump each breast three times a day."
- C. "Apply a heating pad to each breast."
- D. "Wear a well-fitting bra for the first 5 to 6 days."
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
- Wearing a well-fitting bra provides support and pressure on the breasts, which can help decrease milk production and relieve discomfort during lactation suppression.
- Warm showers, pumping, and applying a heating pad can actually stimulate milk production rather than suppress it, so they are not appropriate instructions for lactation suppression.
- Therefore, option D is the correct choice as it promotes effective lactation suppression by providing proper breast support.