Nokea
If the rubella vaccine is indicated for a postpartum patient, which instructions should be provided?
- A. No specific instructions
- B. Drinking plenty of fluids to prevent fever
- C. Recommendation to stop breastfeeding for 24 hours after the injection
- D. Explanation of the risks of becoming pregnant within 28 days following injection
Correct Answer: D
Rationale: The correct answer is D because the rubella vaccine contains live virus and poses a risk to the fetus if the patient becomes pregnant within 28 days of receiving the vaccine. Providing instructions about the risks of pregnancy after vaccination is crucial to prevent potential harm to the fetus.
A: Incorrect - Specific instructions are necessary due to the live virus in the vaccine.
B: Incorrect - Drinking fluids does not address the specific risks associated with pregnancy after vaccination.
C: Incorrect - Stopping breastfeeding is not necessary after receiving the rubella vaccine.
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The nurse has administered Benadryl (diphenhydramine) to a post-cesarean client who is experiencing side effects from the parenteral morphine sulfate that was administered 30 minutes earlier. Which of the following actions should the nurse perform following the administration of the drug?
- A. Monitor the urinary output hourly.
- B. Supervise while the woman holds her newborn.
- C. Position the woman slightly elevated on her left side.
- D. Ask any visitors to leave the room.
Correct Answer: B
Rationale: Supervision ensures safety due to potential sedation.
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.
The nurse is providing care to a patient 2 hours after a cesarean birth. In the hand-off report, he preceding nurse indicated that the patient’s lochia was scant rubra. On initial assessment, the oncoming nurse notes the patient’s peripad is saturated with lochia rubra immediately after breastfeeding her infant. What is the nurse’s priority action with this finding?
- A. Weigh the peripad.
- B. Replace the peripad.
- C. Contact the health care provider.
- D. Document the finding in the patient’s chart.
Correct Answer: C
Rationale: The correct answer is C: Contact the health care provider. This is the priority action because the sudden increase in lochia flow after breastfeeding could indicate postpartum hemorrhage, which is a serious complication that requires immediate medical attention. Contacting the healthcare provider will allow for prompt assessment and intervention.
A: Weigh the peripad - This is not the priority action as assessing the amount of blood loss is important, but contacting the healthcare provider for further assessment and intervention takes precedence.
B: Replace the peripad - While maintaining cleanliness and hygiene is important, addressing the potential postpartum hemorrhage is the priority.
D: Document the finding in the patient’s chart - Documentation is necessary but should come after the immediate concern of postpartum hemorrhage is addressed.
The postpartum nurse has completed discharge teaching for a patient being discharged after an uncomplicated vaginal birth. Which statement by the patient indicates that further teaching is necessary?
- A. “I may not have a bowel movement until the 2nd postpartum day.”
- B. “If I breastfeed and supplemUenSt wiNth fTormula,O I won’t need any birth control.”
- C. “I know my normal pattern of bowel elimination won’t return until about 8 to 10 days.”
- D. “If I am not breastfeeding, I should use birth control when I resume sexual
Correct Answer: B
Rationale: The correct answer is B because the patient's statement about not needing birth control if breastfeeding and supplementing with formula is incorrect. Breastfeeding is not a reliable form of birth control and additional contraception is necessary to prevent unintended pregnancy.
Explanation:
1. Breastfeeding alone is not a foolproof method of contraception.
2. The combination of breastfeeding and formula feeding does not guarantee contraception.
3. Lactational amenorrhea method (LAM) is only effective if specific criteria are met.
4. The patient's misconception about not needing birth control while breastfeeding and supplementing with formula puts her at risk of unintended pregnancy.
Summary:
A: Correct statement about the timing of bowel movements postpartum.
C: Incorrect statement about the normal pattern of bowel elimination postpartum.
D: Correct statement about the need for birth control if not breastfeeding.
Cloxacillin 500 mg by mouth four times per day for 10 days has been ordered for a client with a breast abscess. The client states that she is unable to swallow pills. The oral solution is available as 125 mg/5 mL. How many mL of medicine should the woman take per dose? (Calculate to the nearest whole.)
- A. 20
- B. NA
- C. NA
- D. NA
Correct Answer: A
Rationale: Calculation: 500 mg ÷ 125 mg × 5 mL = 20 mL.