Nokea
A nurse on the postpartum unit is caring for two postoperative cesarean clients. One client had spinal anesthesia for the delivery and the other client had an epidural. Which of the following complications will the nurse monitor the spinal client for that the epidural client is much less high risk for?
- A. Pruritus.
- B. Nausea.
- C. Postural headache.
- D. Respiratory depression.
Correct Answer: C
Rationale: Spinal anesthesia increases the risk of postural headaches.
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Research has shown that with lesbian parents, the non-birthing person can feel role resentment, exclusion from health-care services, and feelings of neglect. How can the nurse include the non-birthing partner?
- A. Ask the person to leave the room during the newborn assessment.
- B. Educate the person to leave the feeding up to the birthing person.
- C. Demonstrate newborn care to both parents.
- D. Ask the person’s family how they feel about their relationship.
Correct Answer: C
Rationale: The correct answer is C: Demonstrate newborn care to both parents. This option promotes inclusivity and involvement of both parents in caring for the newborn, addressing feelings of neglect and exclusion. It allows the non-birthing partner to actively participate in the care process, fostering bonding and reducing role resentment.
A: Asking the person to leave the room during the newborn assessment isolates and excludes them, exacerbating feelings of neglect.
B: Educating the person to leave feeding to the birthing person further marginalizes them and does not address their emotional needs.
D: Asking the person's family about their relationship does not directly involve the non-birthing partner and does not address their feelings of exclusion.
The postpartum nurse is observing a patient holding the baby she delivered less than 24 hours ago. The partner is watching his wife and asking questions about newborn care. The
- A. Report the incident to the social services department.
- B. Advise the parents that the older son needs to be reprimande
- C. No action; this is a normal family adjusting to family change
- D. Report to oncoming staff that the mother is probably not a good disciplinarian.
Correct Answer: C
Rationale: Correct Answer: C - No action; this is a normal family adjusting to family change.
Rationale:
1. It is normal for new parents to have questions and concerns about newborn care.
2. The parents are actively engaged with the newborn and seeking information, indicating a positive adjustment.
3. The mother's behavior with the newborn does not raise any immediate concerns for intervention.
4. Reporting to social services or assuming parenting styles based on limited observation is unwarranted.
Summary:
A: Reporting to social services is unnecessary as there are no signs of neglect or abuse.
B: Reprimanding the older son is unrelated to the situation and inappropriate.
D: Assuming the mother's parenting style based on limited observation is unjustified and unprofessional.
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.
Which description best explains the term reciprocal attachment behavior?
- A. Behavior during the sensitive period when the infant is in the quiet alert stage
- B. Positive feedback that the infant exhibits toward parents during the attachment process
- C. Unidirectional behavior exhibited by the infant, initiated and enhanced by eye contact
- D. Behavior by the infant during the sensitive period to elicit feelings of “falling in love” from the parents
Correct Answer: B
Rationale: The correct answer is B because reciprocal attachment behavior refers to the mutual and positive interactions between infants and their caregivers during the attachment process. This behavior involves the infant responding to the caregiver's actions with positive feedback, such as smiles, cooing, and seeking physical contact. This interaction strengthens the bond between the infant and caregiver.
Choice A is incorrect because it describes the infant's behavior during a specific stage (quiet alert stage) but does not capture the reciprocal nature of attachment behavior. Choice C is incorrect because reciprocal attachment behavior is not unidirectional and does not solely depend on eye contact. Choice D is incorrect because reciprocal attachment behavior is not about eliciting specific feelings from the parents but rather about building a strong, mutual bond between the infant and caregiver.
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.