Nokea
A nurse is providing anticipatory guidance to a couple before they take home their newborn. Which of the following should be included?
- A. If their baby is sleeping soundly
- B. they should not awaken the baby for a feeding.
- C. If they take their baby outside
- D. they should put sunscreen on the baby.
Correct Answer: C
Rationale: Acetaminophen is useful for fever or discomfort under medical supervision.
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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.
The postpartum person asks for only warm drinks and food. How can the nurse support this cultural tradition?
- A. Explain that nurses do not have control over the food.
- B. Tell the person that cold fluids are better for recovery.
- C. Instruct the person to call the nurse to warm up food or drink.
- D. Educate the person on culture in the United States.
Correct Answer: C
Rationale: Rationale for Correct Answer (C): Instructing the person to call the nurse to warm up food or drink is the best way to support the cultural tradition of consuming warm drinks and food. This option respects the individual's cultural preferences and provides a practical solution to meet their needs without imposing personal opinions. By offering assistance in warming up the food or drink, the nurse acknowledges and honors the person's cultural background, promoting a culturally sensitive and patient-centered approach.
Summary of Incorrect Choices:
A: Explaining that nurses do not have control over the food dismisses the person's request and does not address the cultural tradition.
B: Telling the person that cold fluids are better for recovery disregards the cultural preference for warm drinks and food.
D: Educating the person on culture in the United States is not relevant to supporting their specific cultural tradition of consuming warm drinks and food.
A physician writes in a breastfeeding mother's chart, 'Ampicillin 500 mg q 6 h po. Baby should be bottle fed until medication is discontinued.' What should be the nurse's next action?
- A. Follow the order as written.
- B. Call the doctor and question the order.
- C. Follow the antibiotic order but ignore the order to bottle feed the baby.
- D. Refer to a text to see whether the antibiotic is safe while breastfeeding.
Correct Answer: B
Rationale: Ampicillin is generally safe during breastfeeding.
Which assessment finding 24 hours after vaginal birth would indicate a need for further intervention?
- A. Pain level 5 on scale of 0 to 10
- B. Saturated pad over a 2-hour period
- C. Urinary output of 500 mL in one voiding
- D. Uterine fundus 2 cm above the umbilicus
Correct Answer: B
Rationale: The correct answer is B because a saturated pad over a 2-hour period 24 hours after vaginal birth could indicate postpartum hemorrhage, a serious complication requiring immediate intervention. Excessive bleeding can lead to hypovolemic shock and endanger the mother's life. Monitoring and managing postpartum bleeding is crucial to prevent complications.
A: Pain level of 5 is subjective and may vary among individuals. It does not necessarily indicate a need for immediate intervention.
C: Urinary output of 500 mL in one voiding is within the normal range for postpartum women and does not suggest an immediate need for intervention.
D: Uterine fundus 2 cm above the umbilicus is within the expected range for 24 hours postpartum and does not indicate a need for immediate intervention.
The nurse assesses the fundus and finds it to be boggy, elevated >2 fingerbreadths above the umbilicus, and deviated to one side. What is the common cause of this finding?
- A. uterine rupture
- B. full bladder
- C. perineal laceration
- D. hematoma
Correct Answer: B
Rationale: The correct answer is B: full bladder. A full bladder can cause the fundus to be boggy, elevated, and deviated to one side due to impeding the uterus from contracting properly. This can lead to postpartum hemorrhage. Uterine rupture (A) would present with severe abdominal pain and signs of shock. Perineal laceration (C) would not cause these fundus changes. Hematoma (D) would present with localized swelling and pain, not fundal changes.