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A nurse is preparing to perform a fundal assessment on a postpartum client who delivered 12 hours ago. What should the nurse do first?
- A. Lower the head of the bed
- B. Locate the level of the fundus
- C. Assist the woman to the bathroom to empty her bladder
- D. Massage the fundus
Correct Answer: C
Rationale: The correct answer is C: Assist the woman to the bathroom to empty her bladder. This is the first step because a full bladder can displace the uterus, making fundal assessment inaccurate. Emptying the bladder allows for proper fundal assessment by ensuring the uterus is in the correct position. Lowering the head of the bed (choice A) is not necessary before fundal assessment. Locating the level of the fundus (choice B) can be done after ensuring the bladder is empty. Massaging the fundus (choice D) should only be done after fundal assessment to check for firmness.
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The nurse is preparing to perform a visual assessment of the perineum of a postpartum patient. The nurse will use the REEDA acronym. Which specific assessments isn't covered by REEDA?
- A. Perineal coloration
- B. Suture line appearance
- C. Amount of swelling
- D. Description of pain
Correct Answer: D
Rationale: The correct answer is D, Description of pain. The REEDA acronym stands for Redness, Edema, Ecchymosis, Discharge, and Approximation. These components focus on physical aspects like inflammation, bruising, wound healing, and discharge. Pain assessment is important but not part of the REEDA acronym, which specifically addresses visible signs of perineal healing postpartum. A thorough assessment should include pain evaluation separately. Choices A, B, and C are incorrect because they are covered by the REEDA acronym, focusing on perineal coloration, suture line appearance, and amount of swelling, respectively.
The nurse on a postpartum unit is focused on providing care that will assist the mother and father in making the transition to parenthood. For which reason does the nurse review the prenatal and labor records?
- A. Pregnancy and birth experiences, which can either enhance or impede the process of becoming a mother.
- B. Awareness of prenatal classes that will help identify and focus on learning needs of both parents.
- C. Identification of preexisting maternal conditions that may interfere with parenting transitions.
- D. Knowledge regarding questions and concerns the mother and father may have about neonate issues.
Correct Answer: A
Rationale: The correct answer is A: Pregnancy and birth experiences, which can either enhance or impede the process of becoming a mother. Reviewing the prenatal and labor records helps the nurse understand the mother's experiences during pregnancy and childbirth, which can significantly impact her transition to motherhood. By knowing these experiences, the nurse can identify any factors that may enhance or impede the mother's adjustment to motherhood. This information allows the nurse to provide tailored support and interventions to assist the mother in her transition.
Choice B is incorrect because prenatal classes are not directly related to reviewing prenatal and labor records to understand the mother's experiences. Choice C is incorrect as preexisting maternal conditions are not the main focus when reviewing records for the transition to parenthood. Choice D is also incorrect as it focuses on neonate issues, which are not the primary concern when reviewing prenatal and labor records for assisting the mother and father in making the transition to parenthood.
The nurse is preparing to perform a visual assessment of the perineum of a postpartum patient. The nurse will use the REEDA acronym. Which specific assessments isn't covered by REEDA?
- A. Perineal coloration
- B. Suture line appearance
- C. Amount of swelling
- D. Description of pain
Correct Answer: D
Rationale: The correct answer is D, Description of pain. The REEDA acronym stands for Redness, Edema (swelling), Ecchymosis (bruising), Discharge, and Approximation (suture line). Pain description is not specifically covered by REEDA, as it focuses on the physical aspects of the perineal assessment. Describing pain would fall under a separate assessment category such as pain scale assessment. Choices A, B, and C are incorrect because they are all aspects that are included in the REEDA assessment for the perineum.
Which behavior does the nurse identify as a demonstration of unidirectional bonding between a parent and infant?
- A. The parents respond to the baby's cry.
- B. The parents call the baby by name.
- C. The baby responds to comforting measures.
- D. The parents stimulate and entertain the baby.
Correct Answer: B
Rationale: The correct answer is B because calling the baby by name demonstrates unidirectional bonding where the parent initiates the interaction and establishes a connection with the infant. This behavior shows a one-way flow of communication and emotional attachment from the parent to the infant. In contrast, choices A, C, and D involve reciprocal interactions or responses between the parent and infant, indicating bidirectional bonding where both parties are actively engaged in the relationship. Therefore, choices A, C, and D do not exemplify unidirectional bonding as in choice B.
The nurse is preparing to perform a visual assessment of the perineum of a postpartum patient. The nurse will use the REEDA acronym. Which specific assessments isn't covered by REEDA?
- A. Perineal coloration
- B. Suture line appearance
- C. Amount of swelling
- D. Description of pain
Correct Answer: D
Rationale: The correct answer is D, Description of pain. The REEDA acronym stands for Redness, Edema, Ecchymosis, Discharge, and Approximation, focusing on physical characteristics. Pain assessment is important but not part of the REEDA visual assessment. Perineal coloration (A), suture line appearance (B), and amount of swelling (C) are all physical aspects covered by REEDA.