Nokea
A newly delivered mother states, 'I have not had any alcohol since I decided to become pregnant. I have decided not to breastfeed because I would really like to go out and have a good time for a change.' Which of the following is the best response by the nurse?
- A. I understand that being good for so many months can become very frustrating.
- B. Even if you bottle feed the baby
- C. you will have to refrain from drinking alcohol for at least the next six weeks to protect your own health.
- D. Alcohol can be consumed at any time while you are breastfeeding.
Correct Answer: D
Rationale: Metabolizing alcohol ensures safety for the baby.
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The nurse is caring for a birth mother who is relinquishing her newborn. What intervention is appropriate for the nurse?
- A. Use words like “giving away your child” or “giving up for adoption.”
- B. Tell the person not to hold the baby.
- C. Ask the person why she is giving up her baby.
- D. Ask about the patient’s expectations for having newborn photos or video.
Correct Answer: D
Rationale: The correct answer is D because asking about the patient's expectations for newborn photos or video shows empathy and support for the mother's emotional needs during this difficult time. It allows the nurse to provide personalized care and helps the mother create lasting memories.
A: Using phrases like "giving away your child" is insensitive and can be hurtful to the mother.
B: Discouraging the mother from holding the baby can be emotionally damaging and is not supportive.
C: Asking why she is giving up her baby can be intrusive and may not be helpful at this moment.
A client, 1 day postpartum (PP), is being monitored carefully after a significant postpartum hemorrhage. Which of the following should the nurse report to the obstetrician?
- A. Urine output 200 mL for the past 8 hours.
- B. Weight decrease of 2 pounds since delivery.
- C. Drop in hematocrit of 2% since admission.
- D. Pulse rate of 68 beats per minute.
Correct Answer: A
Rationale: Reduced urine output indicates potential hypovolemia.
The nurse is providing care to a patient who delivered a 3525-g infant 14 hours ago. The nurse palpates the fundus of the uterus as firm and at the umbilicus. What is the nurse’s priority action related to this finding?
- A. Inform the health care provider.
- B. Encourage the patient to urinat
- C. Massage the uterus to expel clots.
- D. Document the finding in the patient’s chart.
Correct Answer: D
Rationale: The correct answer is D: Document the finding in the patient’s chart. The fundus being firm and at the umbilicus indicates normal involution after delivery. Documenting this finding is essential for accurate assessment and continuity of care. Informing the health care provider (choice A) is not necessary as the finding is normal. Encouraging the patient to urinate (choice B) is important for postpartum care but not the priority in this situation. Massaging the uterus to expel clots (choice C) is not indicated as the fundus is already firm, indicating proper contraction.
A client who is post-cesarean section for severe preeclampsia is receiving magnesium sulfate via IV pump and morphine sulfate via patient-controlled anesthesia (PCA) pump. The nurse enters the room on rounds and notes that the client is not breathing. Which of the following actions should the nurse perform first?
- A. Give two breaths.
- B. Discontinue medications.
- C. Call a code.
- D. Check carotid pulse.
Correct Answer: A
Rationale: Immediate ventilation is critical.
A breastfeeding woman has been diagnosed with retained placental fragments 4 days postdelivery. Which of the following breastfeeding complications would the nurse expect to see?
- A. Engorgement.
- B. Mastitis.
- C. Blocked milk duct.
- D. Low milk supply.
Correct Answer: B
Rationale: Retained fragments increase infection risk.