Nokea
In the recovery room, the nurse checks the newly delivered woman's fundus following a cesarean section. How would the nurse proceed with this assessment?
- A. Palpate from the midline to the side of the body.
- B. Palpate from the symphysis to the umbilicus.
- C. Palpate from the side of the uterus to the midline.
- D. Massage the abdomen in a circular motion.
Correct Answer: C
Rationale: The fundus is checked gently by walking the fingers from the side of the uterus to the midline.
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The nurse is caring for a woman of Middle Eastern descent on the first postpartum day. Education is provided regarding instruction on use of a sitz bath. What documentation best indicates that the woman has understood the provided instruction?
- A. Patient correctly performed return demonstration.
- B. Patient indicated understanding by nodding head with instruction.
- C. Patient verbalizes 'I understand.'
- D. Family member indicates patient understands procedure.
Correct Answer: A
Rationale: The nurse may need an interpreter to understand and provide optimal care to the woman and her family. A return demonstration is the most reliable indicator of understanding, especially considering cultural nuances where nodding may reflect courtesy rather than comprehension.
On the second postpartum day, a mother bathed her newborn for the first time. She tells the nurse, 'I don't think I did it right.' What postpartum psychological stage is this woman most likely in based on this comment?
- A. Taking in
- B. Taking hold
- C. Letting go
- D. Settling down
Correct Answer: B
Rationale: In phase 2, taking hold, the mother begins to initiate action and becomes interested in caring for the infant. In doing so, she may become critical of her performance.
The nurse is giving a shower to a patient who had a cesarean section 2 days previously. What interventions should be included before, during, and after the shower? (Select all that apply.)
- A. Leave abdominal dressing open to air.
- B. Position patient with back to water stream.
- C. Cover infusion site with rubber glove.
- D. Provide a shower chair.
- E. Confirm ambulation ability.
Correct Answer: B,C,D,E
Rationale: The patient should be evaluated for ambulatory ability, and the abdominal dressing and infusion site should be covered with a waterproof cover. The patient should be provided a shower chair and positioned with her back to the water stream.
A postpartum woman is not immune to rubella. What will the nurse expect?
- A. The rubella virus vaccine should be administered before discharge.
- B. The woman should receive the rubella virus vaccine at her 6-week postpartum checkup.
- C. The woman should be instructed not to get pregnant until she receives the rubella vaccine.
- D. No intervention is indicated at this time because the woman is not at risk for rubella.
Correct Answer: A
Rationale: The woman who is not immune to rubella is immunized in the immediate postpartum period, because there is no danger of her being pregnant.
Which statement indicates the new mother is breastfeeding correctly?
- A. I will alternate breasts when feeding the baby.'
- B. I keep the baby on a 4-hour feeding schedule.'
- C. I let the baby stay on the first breast only 5 minutes.'
- D. I put only the nipple in the baby's mouth when I am breastfeeding.'
Correct Answer: A
Rationale: Alternating breasts for feeding increases milk production, particularly hindmilk, which has a higher protein and fat content.