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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 first step is to assist the woman to the bathroom to empty her bladder. This is important to ensure an accurate fundal assessment, as a full bladder can displace the uterus and lead to incorrect fundal height measurement. Lowering the head of the bed (Choice A) is not necessary for a fundal assessment. Locating the level of the fundus (Choice B) should come after ensuring the bladder is empty. Massaging the fundus (Choice D) is not indicated until after the fundal assessment is completed.
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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 in a postpartum unit frequently teaches patients regarding breast care. Which teaching is most helpful to the breastfeeding patient?
- A. Run warm water over breasts while in the shower.
- B. Wear a supportive bra for 24 hours a day.
- C. Express milk by a breast pump or manually.
- D. Take analgesics for breast pain management.
Correct Answer: C
Rationale: The correct answer is C because expressing milk by a breast pump or manually helps maintain milk supply, prevent engorgement, and relieve discomfort. It also allows for milk storage and feeding flexibility.
A: Running warm water over breasts can lead to oversupply and disrupt milk production.
B: Wearing a bra 24/7 can lead to constriction and may decrease milk flow.
D: Taking analgesics only masks the pain without addressing the underlying issue of milk expression.
The nurse is educating a postpartum woman on how to prevent engorgement. Which action of the patient indicates effective learning?
- A. Breastfeeding the infant every 2 to 3 hours
- B. Avoiding using soap on the breast when bathing
- C. Drinking 8 to 10 glasses of water during the day
- D. Binding the breast with a towel or stretch bandage
Correct Answer: A
Rationale: The correct answer is A because breastfeeding the infant every 2 to 3 hours helps to establish a proper milk supply, prevent engorgement, and ensure adequate milk removal. This frequent nursing schedule stimulates milk production and prevents the breasts from becoming overly full. Choice B is incorrect because avoiding soap on the breast does not directly prevent engorgement. Choice C is incorrect as hydration is important but not the primary method to prevent engorgement. Choice D is incorrect because binding the breast with a towel or stretch bandage can constrict milk flow and lead to engorgement.
The nurse is counseling a lesbian couple who have decided to have a child. Which considerations doesn't the nurse present with regard to which partner will become pregnant?
- A. Consider the age and health of each partner.
- B. Evaluate each partner's career goals.
- C. Decide which partner has better insurance.
- D. Determine who will be on the birth certificate.
Correct Answer: D
Rationale: The correct answer is D because determining who will be on the birth certificate is not a relevant consideration when discussing which partner will become pregnant. The birth certificate can be adjusted later, and it does not impact the decision-making process for pregnancy.
A: Age and health are important factors to consider for the partner who will become pregnant.
B: Evaluating career goals can help determine the impact of pregnancy on each partner's professional life.
C: Insurance coverage can be important when planning for pregnancy and childbirth, as it can affect access to healthcare services.
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 without the need for the baby's response. This action shows a one-way connection from the parent to the infant. In contrast, choices A, C, and D involve mutual interaction between the parent and the baby, indicating bidirectional bonding where both parties are actively engaging with each other. Option A involves the parent responding to the baby's cry, option C involves the baby responding to comforting measures, and option D involves the parents stimulating and entertaining the baby, all of which require reciprocal actions from both the parent and the baby.