Nokea
A postpartum client has been diagnosed with deep vein thrombosis. For which of the following additional complications is this client high risk?
- A. Hemorrhage.
- B. Stroke.
- C. Endometritis.
- D. Hematoma.
Correct Answer: B
Rationale: DVT increases stroke risk due to clot migration.
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A baby boy is to be circumcised by the mother's obstetrician. Which of the following actions shows that the nurse is being a patient advocate?
- A. Before the procedure
- B. the nurse prepares the sterile field for the physician.
- C. The nurse refuses to unclothe the baby until the doctor orders something for pain.
- D. The nurse holds the feeding immediately before the circumcision.
Correct Answer: B
Rationale: Ensuring pain management demonstrates advocacy for the baby's comfort and safety.
The nurse observes a patient on her first postpartum day sitting in bed while her newborn lies awake in the bassinet. Which action is most appropriate for the nurse to take at this time?
- A. Hand the baby to the woman.
- B. Explain “taking-in” to the woman.
- C. Offer to hand the baby to the woman.
- D. No action, because this situation is perfectly acceptabl
Correct Answer: B
Rationale: The correct answer is B: Explain "taking-in" to the woman. This action allows the nurse to educate the woman on the normal postpartum adjustment period. By explaining "taking-in," the nurse helps the woman understand her current need for rest and reflection without feeling guilty about not immediately attending to her newborn. This approach promotes bonding by reducing anxiety and enhancing the mother's confidence in her abilities.
Summary of other choices:
A: Hand the baby to the woman - This choice may not address the woman's emotional needs and understanding of her current state.
C: Offer to hand the baby to the woman - While offering is a good gesture, it may not address the underlying need for education and reassurance.
D: No action, because this situation is perfectly acceptable - Ignoring the opportunity to provide guidance and support may lead to confusion and insecurity for the woman.
The nurse assesses the breasts. What is a warning sign?
- A. colostrum expressed
- B. nipple everted
- C. redness, pain, and heat
- D. filling with milk
Correct Answer: C
Rationale: The correct answer is C because redness, pain, and heat are warning signs of a possible breast infection or inflammation, such as mastitis. This indicates an abnormality that requires further assessment and intervention.
A: Colostrum expressed is a normal occurrence during pregnancy or after delivery and is not a warning sign.
B: Nipple everted is also a normal anatomical variation and not a warning sign.
D: Filling with milk is expected during lactation and not necessarily indicative of a problem.
A nurse is teaching a mother how to care for her 3-day-old son's circumcised penis. Which of the following actions demonstrates that the mother has learned the information?
- A. The mother cleanses the glans with a cotton swab dipped in hydrogen peroxide.
- B. The mother covers the glans with antifungal ointment after rinsing off any discharge.
- C. The mother squeezes soapy water from the wash cloth over the glans.
- D. The mother replaces the dry sterile dressing before putting on the diaper.
Correct Answer: D
Rationale: Proper care involves keeping the area clean and dry, with a sterile dressing if necessary.
A newly delivered mother states, 'I have not had any alcohol since I decided to become pregnant. I have decided not to breastfeed because I would really like to go out and have a good time for a change.' Which of the following is the best response by the nurse?
- A. I understand that being good for so many months can become very frustrating.
- B. Even if you bottle feed the baby
- C. you will have to refrain from drinking alcohol for at least the next six weeks to protect your own health.
- D. Alcohol can be consumed at any time while you are breastfeeding.
Correct Answer: D
Rationale: Metabolizing alcohol ensures safety for the baby.