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A nurse is developing a teaching plan for parents who are taking home their 2-day-old breastfed baby. Which of the following should the nurse include in the plan?
- A. Wash hands well before picking up the baby.
- B. Refrain from having visitors for the first month.
- C. Wear a mask to prevent transmission of a cold.
- D. Sterilize the breast pump supplies after every use.
Correct Answer: A
Rationale: Hand hygiene is crucial to prevent infection.
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A woman who wishes to breastfeed advises the nurse that she had a breast reduction one year earlier. Which of the following responses by the nurse is appropriate?
- A. Advise the woman that unfortunately she will be unable to breastfeed.
- B. Examine the woman's breasts to see where the incision was placed.
- C. Monitor the baby's daily weights for excessive weight loss.
- D. Inform the woman that reduction surgery rarely affects milk transfer.
Correct Answer: C
Rationale: Weight monitoring ensures adequate milk transfer.
During the first 8 hours postpartum, the nurse will demonstrate how to perform a fundal massage and assist with breast-feeding techniques. What other assessment is important at this time?
- A. assessment of partner changing a diaper
- B. assessment of vaginal bleeding
- C. assessment of social support
- D. assessment of family dynamics
Correct Answer: B
Rationale: The correct answer is B: assessment of vaginal bleeding. During the first 8 hours postpartum, it is crucial to monitor vaginal bleeding to assess for any signs of excessive bleeding or hemorrhage, which are common postpartum complications. This assessment helps in early detection and prompt intervention if necessary.
Other choices are incorrect:
A: assessment of partner changing a diaper - While involving the partner in care is beneficial, it is not a priority assessment during this crucial postpartum period.
C: assessment of social support - Important for overall well-being but not as critical as monitoring vaginal bleeding for immediate postpartum complications.
D: assessment of family dynamics - While family dynamics play a role in postpartum care, it is not a priority assessment in the initial 8 hours.
A nurse administered RhoGAM to a client whose blood type is A+ (positive). Which of the following responses would the nurse expect to see? Select all that apply.
- A. Fever.
- B. Flank pain.
- C. Dark-colored urine.
- D. Swelling at the injection site.
Correct Answer: D
Rationale: Localized swelling and dark urine may occur.
A nurse on the postpartum unit is caring for two postoperative cesarean clients. One client had spinal anesthesia for the delivery and the other client had an epidural. Which of the following complications will the nurse monitor the spinal client for that the epidural client is much less high risk for?
- A. Pruritus.
- B. Nausea.
- C. Postural headache.
- D. Respiratory depression.
Correct Answer: C
Rationale: Spinal anesthesia increases the risk of postural headaches.
Which patient is more likely to have less stress adjusting to her role as a mother?
- A. A 26-year-old woman who is returning to work in 10 weeks
- B. A 35-year-old anxious mother who has had no contact with babies or children
- C. A 16-year-old teenager who lives with her parents and has a strained relationship with her mother
- D. A 25-year-old woman who knew at 16 weeks of gestation that she was pregnant with twins, who were delivered by cesarean birth
Correct Answer: A
Rationale: The correct answer is A because the 26-year-old woman who is returning to work in 10 weeks is more likely to have less stress adjusting to her role as a mother. This is because she is likely more established in her career, which can provide a sense of stability and financial security. Additionally, knowing she will return to work in 10 weeks can give her a sense of structure and purpose, reducing uncertainty and stress.
Choice B is incorrect because the 35-year-old anxious mother who has had no contact with babies or children may struggle with feelings of inadequacy and anxiety due to lack of experience with children.
Choice C is incorrect because the 16-year-old teenager living with strained relationship with her mother may face additional stressors from family dynamics and lack of maturity.
Choice D is incorrect because the 25-year-old woman who knew early in her pregnancy and delivered twins by cesarean birth may face physical challenges and increased demands of caring for twins, leading to higher stress levels.