A postpartum patient states, " am really in pain."For which sources of pain will the nurse not assess the patient?
- A. Uterine contractions
- B. Perineal trauma
- C. Breast engorgement
- D. General soreness
Correct Answer: D
Rationale: The correct answer is D because general soreness is a vague and nonspecific term that does not provide any specific information on the source or type of pain. In contrast, uterine contractions, perineal trauma, and breast engorgement are common sources of postpartum pain with specific anatomical locations and characteristics. Assessing for general soreness would not lead to identifying potential underlying issues or appropriate interventions. It is important to focus on assessing specific sources of pain to provide targeted care for the postpartum patient.
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The nurse is researching for evidence-based practice related to a mother's response during the postpartum period. Based on research by Rubin and Mercer, which finding will the nurse be able to easily implement to change the culture of the unit?
- A. Satisfaction questionnaires
- B. Alterations in terminology
- C. Decrease nurse/patient ratios
- D. Soliciting paternal expectations
Correct Answer: B
Rationale: The correct answer is B: Alterations in terminology. Rubin and Mercer's research emphasizes the importance of language in shaping attitudes and behaviors during the postpartum period. By changing the terminology used in the unit to promote positive and empowering language, the nurse can easily implement this finding to change the unit's culture. This can have a significant impact on how mothers perceive their experiences and how they are supported.
Incorrect choices:
A: Satisfaction questionnaires - While important for feedback, satisfaction questionnaires do not directly address changing the culture of the unit.
C: Decrease nurse/patient ratios - This may improve patient care but does not specifically relate to changing the culture of the unit.
D: Soliciting paternal expectations - While involving fathers is important, it does not directly address changing the language and culture of the unit.
The nurse in a postpartum unit evaluates new parents for risk factors that can indicate problems with bonding/attachment. Which situations does the nurse NOT recognize as a cause for bonding/attachment problems?
- A. The mother experienced eclampsia in the third trimester of pregnancy.
- B. The neonate is being treated for meconium aspiration syndrome.
- C. The mother experienced dystocia in the second phase of labor.
- D. The father of the neonate is in the military and not yet home on leave.
Correct Answer: D
Rationale: The correct answer is D. The absence of the father due to military duty does not directly impact bonding/attachment problems.
Rationale:
1. Choice A: Eclampsia can lead to complications during pregnancy but does not directly affect bonding.
2. Choice B: Meconium aspiration syndrome treatment focuses on the neonate's health, not parental bonding.
3. Choice C: Dystocia during labor may lead to physical challenges but does not necessarily affect bonding.
In summary, choices A, B, and C involve medical conditions that could indirectly impact bonding, whereas choice D does not have a direct correlation to bonding/attachment issues.
The nurse is observing a new mother interact with her baby and notices the mother holding the baby close to her body. However, the nurse also notices that the mother does not hold the baby in an enface position. Which question is most appropriate for the nurse to ask?
- A. Can I help you with a nice position in which to hold your baby?'
- B. What can you tell me about your family's beliefs with new babies?'
- C. Is there some reason that I have not seen you look into your baby's eyes?'
- D. Your baby is so expressive, have you looked into his eyes yet?'
Correct Answer: B
Rationale: The correct answer is B because it focuses on understanding the mother's cultural background and beliefs related to interacting with a new baby. This question allows the nurse to gain insight into the mother's perspective and approach to parenting, which can help tailor support and guidance effectively.
Choice A focuses on positioning, which is not the main concern in this scenario. Choice C assumes a negative reason for the mother's behavior without any evidence, potentially causing unnecessary worry. Choice D is too direct and may not be culturally sensitive, as some cultures have different norms regarding eye contact with infants.
The nurse is palpating a patient's uterus 12 hours after a vaginal delivery. For which reason does the nurse place one hand just above the symphysis pubis?
- A. To prevent uterine prolapse.
- B. To prevent uterine movement
- C. To prevent uterine hemorrhage
- D. To prevent uterine inversion
Correct Answer: D
Rationale: The correct answer is D: To prevent uterine inversion. Placing a hand just above the symphysis pubis helps support the uterus and prevent it from turning inside out. This is crucial postpartum to avoid complications such as hemorrhage and shock. Choices A, B, and C are incorrect as palpating the uterus in this manner is specifically aimed at preventing uterine inversion, not prolapse, movement, or hemorrhage.
The nurse is observing a new mother interact with her baby and notices the mother holding the baby close to her body. However, the nurse also notices that the mother does not hold the baby in an enface position. Which question is most appropriate for the nurse to ask?
- A. Can I help you with a nice position in which to hold your baby?'
- B. What can you tell me about your family's beliefs with new babies?'
- C. Is there some reason that I have not seen you look into your baby's eyes?'
- D. Your baby is so expressive, have you looked into his eyes yet?'
Correct Answer: B
Rationale: The correct answer is B: "What can you tell me about your family's beliefs with new babies?". This question is most appropriate as it opens up a dialogue about the mother's cultural or familial practices regarding infant care, which may explain why she is not holding the baby in an enface position. By asking about the family's beliefs, the nurse can gain insight into the mother's perspective and provide culturally sensitive care.
Choice A is incorrect as it assumes the mother needs help without considering her cultural background. Choice C is incorrect as it may come off as judgmental and accusatory. Choice D is incorrect as it focuses on the action of looking into the baby's eyes rather than understanding the cultural context behind the mother's behavior.