Nokea
Postpartum persons who lack attachment with their newborn exhibit what behavior?
- A. intense eye contact
- B. avoid holding the newborn
- C. cuddling
- D. exploring the newborn
Correct Answer: B
Rationale: Lack of attachment is often seen when the postpartum person is disinterested or avoids physical contact such as holding the newborn.
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A nurse is assessing the fundus of a client during the immediate postpartum period. Which of the following actions indicates that the nurse is performing the skill correctly?
- A. The nurse measures the fundal height using a paper centimeter tape.
- B. The nurse stabilizes the base of the uterus with his or her dependent hand.
- C. The nurse palpates the fundus with the tips of his or her fingers.
- D. The nurse precedes the assessment with a sterile vaginal exam.
Correct Answer: B
Rationale: To assess the fundus properly, the nurse should stabilize the base of the uterus with one hand and palpate the fundus with the other.
The nurse suspects that her postpartum client is experiencing hemorrhagic shock. Which observation indicates or would confirm this diagnosis?
- A. Absence of cyanosis in the buccal mucosa
- B. Cool, dry skin
- C. Calm mental status
- D. Urinary output of at least 30 ml/hr
Correct Answer: D
Rationale: The correct answer is D because a urinary output of at least 30 ml/hr indicates adequate perfusion and kidney function, which is crucial in managing hemorrhagic shock. Low urine output is a sign of poor perfusion and impending organ failure. Absence of cyanosis in the buccal mucosa (choice A) is not specific to hemorrhagic shock. Cool, dry skin (choice B) is a late sign of shock. A calm mental status (choice C) can be seen in the compensatory stage of shock.
To prevent infection, the nurse teaches the postpartum client to perform which of the following tasks?
- A. Apply antibiotic ointment to the perineum daily.
- B. Change the peripad at each voiding.
- C. Void at least every two hours.
- D. Spray the perineum with povidone-iodine after toileting.
Correct Answer: B
Rationale: Changing peripads frequently helps prevent the growth of bacteria and reduces the risk of infection.
What nursing intervention does the nurse include in the plan of care for a person with a perineal laceration infection?
- A. Demonstrate the use of a urinary catheter.
- B. Provide an abdominal binder.
- C. Encourage use of the peri-bottle for cleaning front to back.
- D. Discourage use of pain medications.
Correct Answer: C
Rationale: The correct answer is C because using a peri-bottle for cleaning front to back helps prevent introducing more bacteria into the infected perineal laceration. This method maintains proper hygiene, reduces the risk of further infection, and promotes healing. A urinary catheter (A) is not typically indicated for a perineal laceration infection. An abdominal binder (B) may provide support but does not directly address the infection. Discouraging pain medications (D) is not appropriate as pain management is important for patient comfort and healing.
A breastfeeding patient who is 5 weeks postpartum calls the clinic and reports that she is achy all over, has a temperature of 100.2°F, and has pain and tenderness in her right breast. What is the nurse’s best response?
- A. You need to come to the clinic to be evaluated, as your symptoms indicate a possible breast infection.
- B. You are having normal signs of engorgement with breastfeeding. More frequent breastfeeding will relieve your symptoms.
- C. Please stop breastfeeding until you can come to see the clinic provider, as you may have a breast infection.
- D. You may be experiencing sleep deprivation, which can make you feel achy and sore. Try to sleep when the newborn sleeps.
Correct Answer: A
Rationale: The correct answer is A because the patient's symptoms of achiness, fever, and pain in the breast are indicative of mastitis, a common breast infection in breastfeeding women. Prompt evaluation and treatment are necessary to prevent complications.
Choice B is incorrect as engorgement typically occurs in the first few days postpartum, not at 5 weeks.
Choice C is incorrect because stopping breastfeeding can worsen the infection and affect milk production.
Choice D is incorrect as the symptoms described are more likely due to an infection rather than just sleep deprivation.