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In an attempt to improve the effectiveness of postpartum teaching, the nurse uses the AWHONN acronym POST BIRTH. Which teaching points require the patient to call for 911 assistance? Select all that apply.
- A. Bleeding that soaks a pad per hour
- B. A bad headache with vision changes
- C. Thoughts of hurting self or baby
- D. Signs an incision is not healing
Correct Answer: C
Rationale: The correct answer is C: Thoughts of hurting self or baby. This teaching point requires immediate 911 assistance as it indicates a potential risk of harm. It is crucial to prioritize safety in such situations to prevent harm to the patient or the baby. Options A, B, and D are important concerns but do not require immediate 911 assistance. Bleeding that soaks a pad per hour may indicate postpartum hemorrhage, a bad headache with vision changes could be a sign of preeclampsia, and signs of incision not healing may indicate infection. These situations require prompt medical attention but not necessarily emergency assistance via 911.
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A nurse is providing postpartum care to a G4P4 woman who gave birth vaginally 48 hours ago to a 9 pound 10 ounce boy with only a pudendal block for anesthesia. The physician has written orders for the woman to have a sitz bath three times a day. Which information is most closely correlated with the order?
- A. The woman is multiparous.
- B. The woman has an episiotomy.
- C. The woman had a vaginal birth.
- D. The woman received a pudendal block for anesthesia.
Correct Answer: B
Rationale: The correct answer is B because having an episiotomy is directly related to the need for a sitz bath postpartum. An episiotomy is a surgical incision made in the perineum during childbirth to enlarge the vaginal opening, which can cause discomfort and swelling postpartum. A sitz bath helps to soothe and cleanse the area, promote healing, and reduce the risk of infection.
Choice A (The woman is multiparous) is incorrect as the number of pregnancies does not directly correlate with the need for a sitz bath.
Choice C (The woman had a vaginal birth) is incorrect because all women who give birth vaginally can benefit from a sitz bath, not just this woman specifically.
Choice D (The woman received a pudendal block for anesthesia) is incorrect as the type of anesthesia used does not determine the need for a sitz bath; it is more related to the presence of an episiotomy.
In an attempt to improve the effectiveness of postpartum teaching, the nurse uses the AWHONN acronym POST BIRTH. Which teaching points require the patient to call for 911 assistance? Select all that apply.
- A. Bleeding that soaks a pad per hour
- B. A bad headache with vision changes
- C. Thoughts of hurting self or baby
- D. Signs an incision is not healing
Correct Answer: C
Rationale: The correct answer is C: Thoughts of hurting self or baby. This teaching point requires the patient to call for 911 assistance because it indicates a serious mental health emergency, such as postpartum depression or psychosis, which can lead to harm. It is crucial for immediate intervention by trained professionals.
A: Bleeding that soaks a pad per hour is concerning but does not necessarily require immediate 911 assistance unless accompanied by other severe symptoms like dizziness or fainting.
B: A bad headache with vision changes may indicate severe conditions like preeclampsia, which requires urgent medical attention but not necessarily a 911 call unless the symptoms worsen rapidly.
D: Signs an incision is not healing, while important to monitor, does not typically warrant a 911 call unless there are signs of infection or severe complications.
In summary, only choice C requires immediate 911 assistance due to the severe nature of mental health emergencies.
Prior to discharge from the birthing center, the nurse informs the patient that she will receive vaccines for rubella, hepatitis B, pertussis, and influenza. For which reason does the nurse explain the need for the vaccinations?
- A. Discharge with a neonate is discouraged if the mother is not vaccinated.
- B. Vaccinating the mother will protect the neonate from serious illnesses.
- C. The mother's immune system has been suppressed during pregnancy.
- D. Vaccination is more easily accomplished while the mother is under medical care.
Correct Answer: B
Rationale: Step 1: Vaccinating the mother before discharge is important to protect the neonate.
Step 2: Maternal vaccines provide passive immunity to the newborn through transplacental transfer of antibodies.
Step 3: This protection is crucial as newborns have immature immune systems and are vulnerable to infections.
Step 4: Rubella, hepatitis B, pertussis, and influenza are serious illnesses that can be prevented through maternal immunization.
Step 5: Therefore, the correct answer is B as it aligns with the concept of maternal vaccination for the benefit of the neonate.
Summary:
A: Incorrect. Discharge is not based on the mother's vaccination status but on the overall health of both mother and neonate.
C: Incorrect. Pregnancy does not suppress the immune system to the extent that maternal vaccination is contraindicated.
D: Incorrect. Vaccination is recommended based on the timing of administration, not solely on the mother's medical care status.
A nurse is providing postpartum care to a G4P4 woman who gave birth vaginally 48 hours ago to a 9 pound 10 ounce boy with only a pudendal block for anesthesia. The physician has written orders for the woman to have a sitz bath three times a day. Which information is most closely correlated with the order?
- A. The woman is multiparous.
- B. The woman has an episiotomy.
- C. The woman had a vaginal birth.
- D. The woman received a pudendal block for anesthesia.
Correct Answer: B
Rationale: The correct answer is B: The woman has an episiotomy. The rationale is that a sitz bath is commonly recommended postpartum for women who have had an episiotomy to promote healing and reduce discomfort. An episiotomy is a surgical incision made in the perineum during childbirth to widen the vaginal opening. In this case, the woman had a vaginal birth and received a pudendal block for anesthesia, which are not directly correlated with the sitz bath order. Being multiparous (choice A) does not necessarily indicate the need for a sitz bath. Therefore, the most closely correlated information with the sitz bath order is the presence of an episiotomy.
A new mother expresses frustration about how to know what her baby wants. The mother states, 'I don't know what I expect, but then, the baby doesn't know either.' Which situation does the nurse use as an example of neonate communication?
- A. The baby is content to lie still on the mother's abdomen.
- B. The baby is easily awakened if irritated by loud noises.
- C. The baby resists eye contact if bored or disinterested.
- D. The baby roots for the breast when the cheek is stroked.
Correct Answer: D
Rationale: The correct answer is D because rooting reflex is a classic example of neonate communication. When the baby's cheek is stroked, they turn their head in the direction of the touch in search of the breast for feeding. This reflex demonstrates the baby's ability to communicate their hunger needs. This action is instinctual and essential for the baby's survival.
Choices A, B, and C are incorrect because they do not directly relate to neonate communication. Choice A focuses on the baby's physical position rather than communication. Choice B mentions the baby's sensitivity to loud noises, which is more about sensory response than communication. Choice C refers to eye contact, which is not a typical form of communication for newborns.