A new mother expresses frustration about how to know what her baby wants. The mother states, 'I don't know what I expect, but then, the baby doesn't know either.' Which situation does the nurse use as an example of neonate communication?
- A. The baby is content to lie still on the mother's abdomen.
- B. The baby is easily awakened if irritated by loud noises.
- C. The baby resists eye contact if bored or disinterested.
- D. The baby roots for the breast when the cheek is stroked.
Correct Answer: D
Rationale: The correct answer is D because rooting reflex is a clear example of neonate communication. When the baby's cheek is stroked, the baby turns its head in the direction of the touch, indicating a desire for feeding. This reflexive behavior demonstrates the baby's ability to communicate its needs for nourishment.
A: The baby being content to lie still on the mother's abdomen does not directly relate to communication.
B: Being easily awakened by loud noises is a sensory response but not specifically a form of communication.
C: Resisting eye contact if bored or disinterested involves more complex social cues and is not typically seen in neonatal communication.
In summary, choice D is correct as it directly involves a neonatal communication reflex, while the other choices do not demonstrate clear communication cues in the context of a newborn baby.
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The postpartum nurse is planning a home visit to a mother who delivered her baby 1 week ago. Which finding indicates to the nurse a possible problem with mother–infant bonding?
- A. The mother is pleased to have the nurse visit her home and baby.
- B. The baby's grandmother is present and involved with mother/baby care.
- C. The mother focuses the visit on her physical recovery and concerns.
- D. The baby's father is on 'paternity leave' and involved with the baby.
Correct Answer: C
Rationale: The correct answer is C because when a mother primarily focuses on her physical recovery and concerns during a home visit, it may indicate a possible problem with mother-infant bonding. This is because bonding involves emotional connection, interaction, and care between the mother and baby, which goes beyond physical recovery.
A: The mother being pleased to have the nurse visit her home and baby is a positive sign of engagement and interest in the baby's well-being.
B: The baby's grandmother being present and involved with mother/baby care can actually enhance bonding by providing support and assistance.
D: The baby's father being on 'paternity leave' and involved with the baby is another positive sign of family support and involvement in bonding.
The physician has ordered the rubella vaccine to be given to a postpartum woman who is being discharged. Which should be included when providing education about the vaccine to the woman?
- A. Breastfeeding is contraindicated.
- B. The woman should avoid becoming pregnant after receiving the vaccine.
- C. The vaccine can safely be given to women with egg allergies.
- D. The woman must be separated from her infant for 24 hours after receiving the vaccine.
Correct Answer: B
Rationale: The correct answer is B because rubella vaccine is a live attenuated vaccine, which means it should not be given to pregnant women as it can potentially harm the fetus. Therefore, it is important for the postpartum woman to avoid becoming pregnant after receiving the vaccine to prevent any risks to future pregnancies.
Choice A is incorrect as breastfeeding is not contraindicated with the rubella vaccine. Choice C is incorrect because the rubella vaccine should not be given to individuals with severe egg allergies. Choice D is incorrect as there is no need for the woman to be separated from her infant after receiving the rubella vaccine.
Prior to discharge from the birthing center, the nurse informs the patient that she will receive vaccines for rubella, hepatitis B, pertussis, and influenza. For which reason does the nurse explain the need for the vaccinations?
- A. Discharge with a neonate is discouraged if the mother is not vaccinated.
- B. Vaccinating the mother will protect the neonate from serious illnesses.
- C. The mother's immune system has been suppressed during pregnancy.
- D. Vaccination is more easily accomplished while the mother is under medical care.
Correct Answer: B
Rationale: Step-by-step rationale for why choice B is correct:
1. Vaccinating the mother will stimulate her immune system to produce antibodies against rubella, hepatitis B, pertussis, and influenza.
2. These antibodies can pass through the placenta to the neonate, providing passive immunity and protecting the baby from serious illnesses.
3. Newborns have immature immune systems, making them vulnerable to infections, so maternal vaccination is crucial.
4. This approach also helps protect the neonate during the early months when they are too young to receive vaccines themselves.
Summary of why the other choices are incorrect:
A. Discharge with a neonate is not contingent on the mother's vaccination status.
C. The mother's immune system is not necessarily suppressed during pregnancy; vaccination is still recommended.
D. Vaccination can be done post-discharge, but protecting the neonate is the primary reason for vaccinating the mother before discharge.
The nurse is providing postpartum care to a patient 24 hours after a vaginal delivery. Which action does the nurse perform prior to assessing the patient's uterus?
- A. Place the patient on the left side.
- B. Assess the passage of lochia.
- C. Ask the patient to void.
- D. Administer a dose of oxytocin.
Correct Answer: C
Rationale: The correct answer is C: Ask the patient to void. This action is performed prior to assessing the patient's uterus because a full bladder can displace the uterus, leading to inaccurate assessment of uterine size and position. By asking the patient to void, the nurse ensures an accurate assessment of the uterus. Placing the patient on the left side (choice A) is important for preventing supine hypotension but is not directly related to assessing the uterus. Assessing the passage of lochia (choice B) is important postpartum, but it can be done after checking the uterus. Administering a dose of oxytocin (choice D) may be indicated to prevent postpartum hemorrhage, but it is not the first step in assessing the patient's uterus.
Which statement should alert the nurse to the possibility of ineffective bonding between mother and newborn?
- A. "My baby has my eyes."
- B. "No one in my family has that big of a nose."
- C. "Where did he get those long fingers?"
- D. "Is it normal for him to sleep so much?"
Correct Answer: C
Rationale: The correct answer is C because the statement "Where did he get those long fingers?" indicates a lack of recognition or acceptance of the newborn's physical characteristics, which may suggest a disconnect or lack of bonding between the mother and the baby. This statement does not show the mother identifying any physical traits of herself in the baby, unlike choices A and B. Choice D is a common concern among new parents and does not necessarily indicate ineffective bonding. In summary, choice C is correct as it demonstrates a potential lack of bonding based on the mother's statement about the baby's physical features, while the other choices do not indicate the same level of concern.