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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 typical neonatal behavior where babies turn their head and open their mouth to search for a nipple when their cheek is touched. This reflex indicates the baby's communication of hunger and readiness to feed. This behavior is innate and essential for the baby's survival. In contrast, choices A, B, and C do not specifically demonstrate neonatal communication. Choice A does not involve any active communication or response from the baby. Choice B relates to a sensitivity to external stimuli rather than intentional communication. Choice C describes behavior that may not necessarily indicate communication but rather a lack of interest or engagement.
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In an attempt to improve the effectiveness of postpartum teaching, the nurse uses the AWHONN acronym POST BIRTH. Which teaching points require the patient to call for 911 assistance? Select all that apply.
- A. Bleeding that soaks a pad per hour
- B. A bad headache with vision changes
- C. Thoughts of hurting self or baby
- D. Signs an incision is not healing
Correct Answer: C
Rationale: The correct answer is C: Thoughts of hurting self or baby. This teaching point requires the patient to call for 911 assistance because it indicates a serious mental health emergency that needs immediate intervention to ensure the safety of the patient and the baby. Thoughts of harming oneself or the baby are signs of a potential crisis that requires urgent professional help.
Other choices:
A: Bleeding that soaks a pad per hour - This is a concerning sign but does not necessarily require 911 assistance unless it is accompanied by other severe symptoms.
B: A bad headache with vision changes - This could indicate a serious condition like preeclampsia, but it does not always require immediate 911 assistance unless it is severe and life-threatening.
D: Signs an incision is not healing - While this may require medical attention, it does not typically necessitate calling 911 unless there are signs of infection or severe complications.
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 is important prior to assessing the patient's uterus because a full bladder can displace the uterus and make it difficult to accurately assess its position and firmness. By asking the patient to void, the nurse ensures a more accurate assessment of the uterus. Placing the patient on the left side (A) is a position used to maximize uterine perfusion but is not necessary prior to assessing the uterus. Assessing the passage of lochia (B) is important but can be done after assessing the uterus. Administering oxytocin (D) may be indicated to help prevent postpartum hemorrhage but is not necessary prior to assessing the uterus.
In an attempt to improve the effectiveness of postpartum teaching, the nurse uses the AWHONN acronym POST BIRTH. Which teaching points require the patient to call for 911 assistance? Select all that apply.
- A. Bleeding that soaks a pad per hour
- B. A bad headache with vision changes
- C. Thoughts of hurting self or baby
- D. Signs an incision is not healing
Correct Answer: C
Rationale: The correct answer is C: Thoughts of hurting self or baby. This teaching point requires the patient to call for 911 assistance because it indicates a serious mental health emergency, such as postpartum depression or psychosis, which can lead to harm. It is crucial for immediate intervention by trained professionals.
A: Bleeding that soaks a pad per hour is concerning but does not necessarily require immediate 911 assistance unless accompanied by other severe symptoms like dizziness or fainting.
B: A bad headache with vision changes may indicate severe conditions like preeclampsia, which requires urgent medical attention but not necessarily a 911 call unless the symptoms worsen rapidly.
D: Signs an incision is not healing, while important to monitor, does not typically warrant a 911 call unless there are signs of infection or severe complications.
In summary, only choice C requires immediate 911 assistance due to the severe nature of mental health emergencies.
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 features, which could be a sign of ineffective bonding. This statement suggests a disconnect between the mother and newborn. In contrast, choices A and B show recognition of shared physical traits, indicating a bond. Choice D, asking about the baby's sleep patterns, is a common concern for new parents and may not necessarily indicate ineffective bonding.
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.