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A nurse is providing postpartum care to a G4P4 woman who gave birth vaginally 48 hours ago to a 9 pound 10 ounce boy with only a pudendal block for anesthesia. The physician has written orders for the woman to have a sitz bath three times a day. Which information is most closely correlated with the order?
- A. The woman is multiparous.
- B. The woman has an episiotomy.
- C. The woman had a vaginal birth.
- D. The woman received a pudendal block for anesthesia.
Correct Answer: B
Rationale: The correct answer is B: The woman has an episiotomy. The rationale is that a sitz bath is commonly recommended postpartum for women who have had an episiotomy to promote healing and reduce discomfort. An episiotomy is a surgical incision made in the perineum during childbirth to widen the vaginal opening. In this case, the woman had a vaginal birth and received a pudendal block for anesthesia, which are not directly correlated with the sitz bath order. Being multiparous (choice A) does not necessarily indicate the need for a sitz bath. Therefore, the most closely correlated information with the sitz bath order is the presence of an episiotomy.
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Which statement should alert the nurse to the possibility of ineffective bonding between mother and newborn?
- A. "My baby has my eyes."
- B. "No one in my family has that big of a nose."
- C. "Where did he get those long fingers?"
- D. "Is it normal for him to sleep so much?"
Correct Answer: C
Rationale: The correct answer is C because the statement "Where did he get those long fingers?" indicates a lack of recognition or acceptance of the newborn's physical traits, which could suggest a disconnect between the mother and infant. This statement may signal that the mother is not bonding effectively with the baby. In contrast, choices A, B, and D all demonstrate a degree of recognition or concern for the baby's physical characteristics or behaviors, which are more indicative of normal bonding behaviors between a mother and newborn.
In an attempt to improve the effectiveness of postpartum teaching, the nurse uses the AWHONN acronym POST BIRTH. Which teaching points require the patient to call for 911 assistance? Select all that apply.
- A. Bleeding that soaks a pad per hour
- B. A bad headache with vision changes
- C. Thoughts of hurting self or baby
- D. Signs an incision is not healing
Correct Answer: C
Rationale: The correct answer is C: Thoughts of hurting self or baby. This teaching point requires the patient to call for 911 assistance because it indicates a serious mental health emergency, such as postpartum depression or psychosis, which can lead to harm. It is crucial for immediate intervention by trained professionals.
A: Bleeding that soaks a pad per hour is concerning but does not necessarily require immediate 911 assistance unless accompanied by other severe symptoms like dizziness or fainting.
B: A bad headache with vision changes may indicate severe conditions like preeclampsia, which requires urgent medical attention but not necessarily a 911 call unless the symptoms worsen rapidly.
D: Signs an incision is not healing, while important to monitor, does not typically warrant a 911 call unless there are signs of infection or severe complications.
In summary, only choice C requires immediate 911 assistance due to the severe nature of mental health emergencies.
The nurse is providing postpartum care to a patient 24 hours after a vaginal delivery. Which action does the nurse perform prior to assessing the patient's uterus?
- A. Place the patient on the left side.
- B. Assess the passage of lochia.
- C. Ask the patient to void.
- D. Administer a dose of oxytocin.
Correct Answer: C
Rationale: The correct answer is C: Ask the patient to void. It is important to ask the patient to void before assessing the uterus to ensure that the bladder is empty, which allows for a more accurate assessment of the uterus size and position. This helps prevent displacement of the uterus due to a full bladder, leading to a more accurate assessment of postpartum hemorrhage risk. Placing the patient on the left side (A) is done after assessing the uterus to facilitate uterine involution. Assessing the passage of lochia (B) is important but not a priority before assessing the uterus. Administering oxytocin (D) may be indicated but should be based on assessment findings rather than being the first action.
Prior to discharge from the birthing center, the nurse informs the patient that she will receive vaccines for rubella, hepatitis B, pertussis, and influenza. For which reason does the nurse explain the need for the vaccinations?
- A. Discharge with a neonate is discouraged if the mother is not vaccinated.
- B. Vaccinating the mother will protect the neonate from serious illnesses.
- C. The mother's immune system has been suppressed during pregnancy.
- D. Vaccination is more easily accomplished while the mother is under medical care.
Correct Answer: B
Rationale: Step-by-step rationale for why choice B is correct:
1. Vaccinating the mother will stimulate her immune system to produce antibodies against rubella, hepatitis B, pertussis, and influenza.
2. These antibodies can pass through the placenta to the neonate, providing passive immunity and protecting the baby from serious illnesses.
3. Newborns have immature immune systems, making them vulnerable to infections, so maternal vaccination is crucial.
4. This approach also helps protect the neonate during the early months when they are too young to receive vaccines themselves.
Summary of why the other choices are incorrect:
A. Discharge with a neonate is not contingent on the mother's vaccination status.
C. The mother's immune system is not necessarily suppressed during pregnancy; vaccination is still recommended.
D. Vaccination can be done post-discharge, but protecting the neonate is the primary reason for vaccinating the mother before discharge.
The physician has ordered the rubella vaccine to be given to a postpartum woman who is being discharged. Which should be included when providing education about the vaccine to the woman?
- A. Breastfeeding is contraindicated.
- B. The woman should avoid becoming pregnant after receiving the vaccine.
- C. The vaccine can safely be given to women with egg allergies.
- D. The woman must be separated from her infant for 24 hours after receiving the vaccine.
Correct Answer: B
Rationale: The correct answer is B: The woman should avoid becoming pregnant after receiving the vaccine. This is because the rubella vaccine contains a live virus that could potentially harm a developing fetus if the woman were to become pregnant shortly after receiving the vaccine. It is recommended to wait at least 1 month after vaccination before trying to conceive.
Choice A is incorrect because breastfeeding is not contraindicated after receiving the rubella vaccine. Choice C is incorrect as women with severe egg allergies should not receive the rubella vaccine due to potential allergic reactions. Choice D is incorrect as there is no need for the woman to be separated from her infant after receiving the rubella vaccine.