Nokea
On admission to the maternity unit, it is learned that a mother has smoked 2 packs of cigarettes per day and expects to continue to smoke after discharge. The mother also states that she expects to breastfeed her baby. The nurse's response should be based on which of the following?
- A. Breastfeeding is contraindicated if the mother smokes cigarettes.
- B. Breastfeeding is protective for the baby and should be encouraged.
- C. A 2-pack-a-day smoker should be reported to child protective services for child abuse.
- D. A mother who admits to smoking cigarettes may also be abusing illicit substances.
Correct Answer: B
Rationale: Breastfeeding provides benefits despite maternal smoking.
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The nurse is caring for a birth mother who is relinquishing her newborn. What intervention is appropriate for the nurse?
- A. Use words like “giving away your child” or “giving up for adoption.”
- B. Tell the person not to hold the baby.
- C. Ask the person why she is giving up her baby.
- D. Ask about the patient’s expectations for having newborn photos or video.
Correct Answer: D
Rationale: The correct answer is D because asking about the patient's expectations for newborn photos or video shows empathy and support for the mother's emotional needs during this difficult time. It allows the nurse to provide personalized care and helps the mother create lasting memories.
A: Using phrases like "giving away your child" is insensitive and can be hurtful to the mother.
B: Discouraging the mother from holding the baby can be emotionally damaging and is not supportive.
C: Asking why she is giving up her baby can be intrusive and may not be helpful at this moment.
What type of lochia is bright to dark red and occurs on days 1–3 postpartum?
- A. rubra
- B. serosa
- C. placental
- D. alba
Correct Answer: A
Rationale: The correct answer is A: rubra. Lochia rubra is bright to dark red, typically occurring on days 1-3 postpartum. This is due to the presence of blood and decidual tissue. Serosa (B) is pinkish-brown and occurs around days 4-10, representing a mix of blood and mucus. Placental (C) is typically expelled within 30 minutes postpartum and consists of dark red blood. Alba (D) is whitish-yellow, appearing around day 10 and lasting up to 6 weeks, indicating the final stage of lochia consisting of leukocytes and decidual tissue.
A client who received a spinal for her cesarean delivery is complaining of pruritus and has a macular rash on her face and arms. Which of the following medications ordered by the anesthesiologist should the nurse administer at this time?
- A. Reglan (metoclopramide).
- B. Zofran (ondansetron).
- C. Compazine (prochlorperazine).
- D. Benadryl (diphenhydramine).
Correct Answer: D
Rationale: Benadryl treats allergic reactions.
Four newborns were admitted into the neonatal nursery 1 hour ago. They are all sleeping in overhead warmers. Which of the babies should the nurse ask the neonatologist to evaluate?
- A. The neonate with a temperature of 98.9°F and weight of 3
- B. 000 grams.
- C. The neonate with white spots on the bridge of the nose.
- D. The neonate with raised white specks on the gums.
Correct Answer: D
Rationale: Tachypnea and tachycardia may indicate respiratory distress or sepsis.
A postpartum patient calls the clinic and reports to the nurse feelings of fatigue, tearfulness, and anxiety. What is the nurse’s most appropriate response at this time?
- A. “When did these symptoms begin?”
- B. “Sounds like normal postpartum depression.”
- C. “Are you having trouble getting enough sleep?”
- D. “Are you able to get out of bed and provide care for your baby?”
Correct Answer: A
Rationale: The correct answer is A: "When did these symptoms begin?" The nurse's response should address the patient's concerns and gather more information to assess the situation accurately. By asking when the symptoms began, the nurse can determine the duration and severity of the symptoms, enabling appropriate intervention.
Choice B is incorrect because assuming the symptoms are due to "normal postpartum depression" without further assessment is premature and may overlook other potential causes. Choice C focuses solely on sleep and may not address the underlying issues causing the patient's symptoms. Choice D assumes the patient's ability to provide care for the baby without first addressing the patient's emotional well-being.