Nokea
A nurse is working on the postpartum unit. Which of the following patients should the nurse assess first?
- A. PP1 from vaginal delivery with complaints of burning on urination.
- B. PP2 from forceps delivery with blood loss of 500 mL at time of delivery.
- C. PP3 from vacuum delivery with hemoglobin of 7.2 g/dL.
- D. PO4 from cesarean delivery with complaints of firm and painful breasts.
Correct Answer: C
Rationale: Severe anemia requires immediate attention.
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The nurse screens for risk factors such as an infant in the neonatal intensive care unit (NICU), difficulty in role transition, birth complications, unmet social and physical needs, and lack of partner support for what complication?
- A. maladaptive parenting
- B. psychosis
- C. postpartum depression
- D. bipolar disorder
Correct Answer: C
Rationale: The correct answer is C: postpartum depression. Screening for risk factors such as a baby in the NICU, difficulty in role transition, birth complications, unmet social and physical needs, and lack of partner support are all associated with an increased risk for postpartum depression. Postpartum depression is a common complication that affects many new mothers and can have significant impacts on both the mother and the baby's well-being. It is important for healthcare providers to be vigilant in screening for these risk factors to identify and support mothers at risk for postpartum depression.
Summary:
A: maladaptive parenting - Not directly related to the risk factors listed.
B: psychosis - Not typically associated with the listed risk factors.
D: bipolar disorder - While bipolar disorder can occur postpartum, the listed risk factors are more specifically linked to postpartum depression.
A 2-day-old, exclusively breastfed baby is to be discharged home. Under what conditions should the nurse teach the parents to call the pediatrician?
- A. If the baby feeds 8 to 12 times each day.
- B. If the baby urinates 6 to 10 times each day.
- C. If the baby has stools that are watery and bright yellow.
- D. If the baby has eyes and skin that are tinged yellow.
Correct Answer: D
Rationale: Jaundice may indicate hyperbilirubinemia.
To assess fundal contraction 6 hours after cesarean birth, which technique should the nurse utilize?
- A. Assess lochial flow rather than palpating the fundus.
- B. Palpate forcefully through the abdominal dressing.
- C. Place hands on both sides of the abdomen and press downwar
- D. Gently palpate, applying the same technique used for vaginal deliveries.
Correct Answer: D
Rationale: The correct answer is D. Gently palpating the fundus is the appropriate technique after cesarean birth to assess fundal contraction. This technique is recommended to prevent causing discomfort or dislodging the uterus. Assessing lochial flow (A) does not directly evaluate fundal contraction. Palpating forcefully through the abdominal dressing (B) can be painful and may not provide an accurate assessment. Placing hands on both sides of the abdomen and pressing downward (C) is not a recommended technique as it can potentially cause uterine displacement.
A new father calls the nurse’s station stating that his wife, who delivered last week, is happy one minute and crying the next. He states, “She was never like this before the baby was born.” How should the nurse best respond?
- A. Reassure him that this behavior is normal.
- B. Advise him to get immediate psychological help for her.
- C. Tell him to ignore the mood swings because they will go away.
- D. Instruct him in the signs, symptoms, and duration of postpartum blues.
Correct Answer: A
Rationale: The correct answer is A. The nurse should reassure the father that his wife's behavior of mood swings is normal after childbirth due to hormonal changes and adjustment to new responsibilities. This response validates the father's concerns, provides education on common postpartum experiences, and offers support.
Incorrect choices:
B: Immediate psychological help is not warranted for typical postpartum mood swings.
C: Ignoring the mood swings can lead to misunderstandings and lack of support for the mother.
D: Instructing on postpartum blues is more clinical and may not address the father's immediate concerns.
The nurse is caring for a client, G3 P2002, whose infant has been diagnosed with a treatable birth defect. Which of the following is an appropriate statement for the nurse to make?
- A. Thank goodness. It could have been untreatable.
- B. I'm so happy that you have other children who are healthy.
- C. These things happen. They are the will of God.
- D. It is appropriate for you to cry at a time like this.
Correct Answer: D
Rationale: Validation of emotions is supportive.