A woman, 26 weeks' gestation, has just delivered a fetal demise. Which of the following nursing actions is appropriate at this time?
- A. Remind the mother that she will be able to have another baby in the future.
- B. Dress the baby in a tee shirt and swaddle the baby in a receiving blanket.
- C. Ask the woman if she would like the doctor to prescribe a sedative for her.
- D. Remove the baby from the delivery room as quickly as possible.
Correct Answer: B
Rationale: Providing dignity to the baby is important.
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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.
The nurse educates the postpartum person on bowel discomfort. What instructions would they give?
- A. Limit water intake.
- B. Use laxatives daily.
- C. Ambulate often.
- D. Avoid stool softeners.
Correct Answer: C
Rationale: The correct answer is C: Ambulate often. After childbirth, ambulation helps stimulate bowel movements, preventing constipation. Walking helps promote peristalsis and improves overall bowel function.
Choice A: Limit water intake - Incorrect. Hydration is important for bowel function and limiting water intake can worsen constipation.
Choice B: Use laxatives daily - Incorrect. Daily use of laxatives can lead to dependence and disrupt natural bowel function.
Choice D: Avoid stool softeners - Incorrect. Stool softeners can be beneficial in preventing constipation and should not be avoided without medical advice.
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.
A nurse is doing a newborn assessment on a new admission to the nursery. Which of the following actions should the nurse make when evaluating the baby for developmental dysplasia of the hip (DDH)? Select one that doesn't apply
- A. Grasp the baby's legs with the thumbs on the inner thighs and forefingers on the outer thighs.
- B. Gently adduct and abduct the baby's thighs.
- C. Palpate the trochanter during hip rotation.
- D. Place the baby in a fetal position.
Correct Answer: D
Rationale: These maneuvers help detect instability or asymmetry in the hips indicative of DDH.
A nurse is providing discharge teaching to the parents of a newborn. Which of the following should be included when teaching the parents how to care for the baby's umbilical cord?
- A. Cleanse it with hydrogen peroxide if it starts to smell.
- B. Remove it with sterile tweezers at one week of age.
- C. Call the doctor if greenish drainage appears.
- D. Cover it with sterile dressings until it falls off.
Correct Answer: C
Rationale: Greenish drainage indicates infection and requires medical attention.