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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 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 encouraging the couple to identify mutual expectations of the fathering role promotes open communication and mutual understanding. This intervention fosters collaboration and unity in parenting. Choice B is incorrect because critiquing the father's methods may create tension and hinder his confidence. Choice C is incorrect because providing written materials alone may not address the unique dynamics of the couple's relationship. Choice D is incorrect as it focuses on potential conflict rather than fostering a positive and supportive environment for the father to identify 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.
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: Correct Answer: B - Instruct the mother to void prior to the assessment.
Rationale:
1. Voiding before assessment prevents inaccurate findings due to bladder distension.
2. Empty bladder facilitates fundal assessment and reduces discomfort.
3. Ensures accurate assessment of postpartum lochia flow.
4. Promotes patient comfort and satisfaction.
Summary of Other Choices:
A - Massaging the fundus is important but should not be the initial step.
C - Assessing lochia flow is crucial, but voiding should be prioritized first.
D - Lowering the head of the bed is unnecessary and may cause discomfort.
As a result of the previously mentioned research study, the nurses in a postpartum facility will implement which evidence-based change?
- A. Continue to assess the level of fatigue for the mother during postpartum period.
- B. Assist fathers in recognizing and managing stress and depressive symptoms.
- C. Encourage the father to go home and rest while the mother is hospitalized.
- D. Promote strategies to decrease fatigue during both prenatal and postnatal periods.
Correct Answer: D
Rationale: The correct answer is D because promoting strategies to decrease fatigue during both prenatal and postnatal periods aligns with evidence-based practice to improve maternal health outcomes. This approach acknowledges the importance of preventive measures to address fatigue before and after childbirth. Option A focuses solely on assessing fatigue without addressing interventions to mitigate it. Option B, while relevant, does not directly impact maternal fatigue. Option C overlooks the father's role in supporting the mother and infant. In summary, option D is the most appropriate as it addresses fatigue proactively throughout the perinatal period.
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.