Nokea
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.
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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 the patient to call for 911 assistance because it indicates a serious mental health emergency that needs immediate intervention to ensure the safety of the patient and the baby. Thoughts of harming oneself or the baby are signs of a potential crisis that requires urgent professional help.
Other choices:
A: Bleeding that soaks a pad per hour - This is a concerning sign but does not necessarily require 911 assistance unless it is accompanied by other severe symptoms.
B: A bad headache with vision changes - This could indicate a serious condition like preeclampsia, but it does not always require immediate 911 assistance unless it is severe and life-threatening.
D: Signs an incision is not healing - While this may require medical attention, it does not typically necessitate calling 911 unless there are signs of infection or severe complications.
The nurse is providing postpartum care to a patient 24 hours after a vaginal delivery. Which action does the nurse perform prior to assessing the patient's uterus?
- A. Place the patient on the left side.
- B. Assess the passage of lochia.
- C. Ask the patient to void.
- D. Administer a dose of oxytocin.
Correct Answer: C
Rationale: The correct answer is C: Ask the patient to void. This is important prior to assessing the patient's uterus because a full bladder can displace the uterus and make it difficult to accurately assess its position and firmness. By asking the patient to void, the nurse ensures a more accurate assessment of the uterus. Placing the patient on the left side (A) is a position used to maximize uterine perfusion but is not necessary prior to assessing the uterus. Assessing the passage of lochia (B) is important but can be done after assessing the uterus. Administering oxytocin (D) may be indicated to help prevent postpartum hemorrhage but is not necessary prior to assessing the uterus.
Which statement should alert the nurse to the possibility of ineffective bonding between mother and newborn?
- A. "My baby has my eyes."
- B. "No one in my family has that big of a nose."
- C. "Where did he get those long fingers?"
- D. "Is it normal for him to sleep so much?"
Correct Answer: C
Rationale: The correct answer is C because the statement "Where did he get those long fingers?" indicates a lack of recognition or acceptance of the newborn's physical features, which could be a sign of ineffective bonding. This statement suggests a disconnect between the mother and newborn. In contrast, choices A and B show recognition of shared physical traits, indicating a bond. Choice D, asking about the baby's sleep patterns, is a common concern for new parents and may not necessarily indicate ineffective bonding.
The physician has ordered the rubella vaccine to be given to a postpartum woman who is being discharged. Which should be included when providing education about the vaccine to the woman?
- A. Breastfeeding is contraindicated.
- B. The woman should avoid becoming pregnant after receiving the vaccine.
- C. The vaccine can safely be given to women with egg allergies.
- D. The woman must be separated from her infant for 24 hours after receiving the vaccine.
Correct Answer: B
Rationale: The correct answer is B because rubella vaccine contains live attenuated virus, which can pose a risk to a developing fetus if the woman becomes pregnant shortly after vaccination. This information is crucial for the woman to avoid pregnancy for a certain period after receiving the vaccine.
Choice A is incorrect because breastfeeding is not contraindicated after receiving the rubella vaccine. Choice C is incorrect because the rubella vaccine should not be given to individuals with a severe allergy to eggs. Choice D is incorrect because there is no need for the woman to be separated from her infant after receiving the rubella vaccine.
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. A sitz bath is often recommended postpartum for women who have had an episiotomy to promote healing and relieve discomfort. An episiotomy is a surgical incision made in the perineum during childbirth to facilitate delivery and prevent tearing. The warm water in a sitz bath helps to reduce swelling, promote circulation, and clean the area.
Incorrect choices:
A: The woman is multiparous - Multiparity does not directly correlate with the need for a sitz bath postpartum.
C: The woman had a vaginal birth - While this is true, it does not specifically address the need for a sitz bath.
D: The woman received a pudendal block for anesthesia - Although this information may be relevant to the birth experience, it does not directly relate to the need for a sitz bath postpartum.