Nokea
A nurse who is caring for a mother/newborn dyad on the maternity unit has identified the following nursing diagnosis: Effective breastfeeding. Which of the following would warrant this diagnosis?
- A. Baby's lips are flanged when latched.
- B. Baby feeds every 4 hours.
- C. Baby lost 12% of weight since birth.
- D. Baby's tongue stays behind the gum line.
Correct Answer: A
Rationale: Flanged lips indicate proper latch.
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A client has given birth to a baby girl with a visible birth defect. Which of the following maternal responses would lead the nurse to suspect poor mother-infant bonding?
- A. The mother states,"I'm so tired. Please feed the baby in the nursery for me."
- B. The mother states,"Her eyes look like mine, but her chin is her Dad's."
- C. The mother says,"We have decided to name her Sarah after my mother."
- D. The mother says,"I breastfed her. I still need help swaddling her, though."
Correct Answer: A
Rationale: Avoidance of infant care suggests bonding issues.
The nurse has completed a postpartum assessment on a patient who delivered 1 hour ago. Which amount of lochia consists of a moderate amount?
- A. Saturated peripad
- B. 10 to 15 cm (4- to 6-inch) stain on the peripad
- C. 2.5 to 10 cm (1- to 4-inch) stain on the peripad
- D. Less than a 1-inch stain on the peripad
Correct Answer: B
Rationale: The correct answer is B (10 to 15 cm (4- to 6-inch) stain on the peripad) because a moderate amount of lochia typically indicates a blood stain of 10 to 15 cm within 1 hour postpartum. This amount of lochia signifies a normal postpartum bleeding pattern.
Incorrect answers:
A: Saturated peripad indicates a heavy amount of lochia, not moderate.
C: 2.5 to 10 cm (1- to 4-inch) stain on the peripad is considered light, not moderate.
D: Less than a 1-inch stain on the peripad is minimal lochia, not moderate.
The postpartum patient who continually repeats the story of her labor, birth, and recovery experiences is performing which of the following tasks?
- A. Making the birth experience “real”
- B. Accepting her response to labor and birth
- C. Providing others with her knowledge of events
- D. Taking hold of the events leading to her labor and birth
Correct Answer: A
Rationale: The correct answer is A: Making the birth experience "real." This choice aligns with the concept of emotional processing and integration in the postpartum period. By continually repeating her birth story, the patient is trying to make sense of and come to terms with her experience, making it feel more "real" to her. This process helps her emotionally process the events and transitions she has gone through during labor and birth.
Choices B, C, and D are incorrect:
B: Accepting her response to labor and birth - This choice focuses more on the patient's emotional response rather than the act of repeating the story.
C: Providing others with her knowledge of events - This choice is more about sharing information rather than the internal emotional processing the patient is likely engaging in.
D: Taking hold of the events leading to her labor and birth - This choice suggests a sense of control over the events, which may not necessarily be the primary motivation behind the patient's behavior.
Postpartum persons who lack attachment with their newborn exhibit what behavior?
- A. intense eye contact
- B. avoid holding the newborn
- C. cuddling
- D. exploring the newborn
Correct Answer: B
Rationale: The correct answer is B because avoiding holding the newborn is a sign of lack of attachment in postpartum persons. This behavior indicates a lack of desire or ability to bond with the newborn, which is crucial for healthy emotional development. Intense eye contact (choice A) and cuddling (choice C) are typically associated with bonding behaviors. Exploring the newborn (choice D) can also be a positive behavior showing interest. However, the key indicator of attachment issues is the avoidance of holding the newborn, making choice B the correct answer.
The nurse is developing a standard care plan for the post-cesarean client. Which of the following should the nurse plan to implement?
- A. Maintain client in left lateral recumbent position.
- B. Teach sitz bath use on second postoperative day.
- C. Perform active range-of-motion exercises until ambulating.
- D. Assess central venous pressure during first postoperative day.
Correct Answer: B
Rationale: Sitz baths promote healing and comfort.