Nokea
A nurse is taking care of a G2P2 woman with a third-degree perineal tear during the fourth stage of labor. The nurse should include which intervention in the plan of care during her 12-hour shift?
- A. Assess vital signs every 4 hours.
- B. Keep patient NPO for first 12 hours.
- C. Catheterize patient prior to first ambulation.
- D. Prepare ice pack for application to perineal area.
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Ice pack application helps reduce swelling and pain in the perineal area post-tear.
2. Ice packs can promote vasoconstriction, reducing bleeding risk.
3. Ice packs are non-invasive and can offer immediate relief.
Summary:
A: Assessing vital signs every 4 hours is important but not directly related to perineal tear care.
B: Keeping the patient NPO for 12 hours is unnecessary and may lead to dehydration.
C: Catheterization is not typically required for perineal tear care unless there are specific indications.
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The nurse is providing postpartum care for an adolescent mother and her family. Which factor is most important for the nurse to consider when planning teaching about neonatal care?
- A. The grandparents decided they want to be involved.
- B. The parents need to discuss their expectations of each other.
- C. The mother is determined the father should be involved.
- D. Information must be presented on an age-appropriate level.
Correct Answer: D
Rationale: The correct answer is D: Information must be presented on an age-appropriate level. This is crucial as adolescents may have limited knowledge and understanding of neonatal care. Teaching in a way they can comprehend ensures effective learning.
Incorrect choices:
A: The involvement of grandparents is important but not the most critical factor.
B: Parental expectations are significant, but not directly related to neonatal care teaching.
C: The father's involvement is valuable, but not the primary consideration for teaching about neonatal care.
In summary, choosing answer D ensures effective communication and understanding for the adolescent mother and her family.
The nurse on a postpartum unit is acutely aware that cultural influences impact the patient's process of 'becoming a mother.' For which isn't a cultural influence does the nurse assess?
- A. What amount of time the mother spends in each phase
- B. Differences in the mother's expectation related to ability to rest
- C. How the mother physically recovers from labor and delivery
- D. Mother's involvement in decision making for the first few months
Correct Answer: C
Rationale: The correct answer is C because physical recovery from labor and delivery is a biological process rather than a cultural influence. The nurse assesses cultural influences, such as beliefs and practices, which shape the mother's experience of motherhood. Choices A, B, and D are influenced by cultural factors, such as time spent in each phase, expectations related to rest, and involvement in decision-making, respectively. These aspects reflect how cultural norms, values, and traditions impact the transition to motherhood.
The nurse is providing postpartum care for an adolescent mother and her family. Which factor is most important for the nurse to consider when planning teaching about neonatal care?
- A. The grandparents decided they want to be involved.
- B. The parents need to discuss their expectations of each other.
- C. The mother is determined the father should be involved.
- D. Information must be presented on an age-appropriate level.
Correct Answer: D
Rationale: The correct answer is D. It is crucial for the nurse to present information on neonatal care in an age-appropriate manner as the mother is an adolescent. This is important to ensure effective communication and understanding. Choice A does not directly impact the neonatal care teaching. Choice B focuses on the parents' expectations, not the neonatal care itself. Choice C emphasizes the father's involvement but does not address the approach to teaching the adolescent mother about neonatal care.
The nurse is preparing a postpartum patient for discharge. Which patient teaching is most important for the nurse to provide?
- A. The signs and symptoms of uterine infection
- B. The signs and symptoms of secondary hemorrhage
- C. The signs and symptoms of postpartum depression
- D. The signs and symptoms of a boggy uterus
Correct Answer: B
Rationale: The correct answer is B: The signs and symptoms of secondary hemorrhage. This is the most important teaching because postpartum hemorrhage can be life-threatening and requires immediate medical attention. The other choices, while important, are not as urgent as secondary hemorrhage. A: Uterine infection signs and symptoms can develop gradually and usually do not pose an immediate threat. C: Postpartum depression is a serious concern but does not require immediate medical intervention. D: A boggy uterus can be a sign of uterine atony but does not necessarily indicate an emergency situation like secondary hemorrhage.
The nurse on a postpartum unit is acutely aware that cultural influences impact the patient's process of 'becoming a mother.' For which isn't a cultural influence does the nurse assess?
- A. What amount of time the mother spends in each phase
- B. Differences in the mother's expectation related to ability to rest
- C. How the mother physically recovers from labor and delivery
- D. Mother's involvement in decision making for the first few months
Correct Answer: C
Rationale: Rationale: The correct answer is C because physical recovery from labor and delivery is a biological process, not solely influenced by culture. Other choices (A, B, D) relate to cultural factors affecting the mother's transition to motherhood, such as rituals, beliefs, and social expectations. Cultural influence can affect the time spent in each phase, expectations related to rest, and decision-making processes. It is crucial for the nurse to assess these cultural influences to provide culturally competent care.