Nokea
Several hours after delivery, a new mother expresses ambivalence regarding her infant. How will the nurse promote bonding?
- A. Having the mother feed the infant
- B. Removing the infant from the mother's arms if it cries
- C. Positioning the infant so its head rests on the mother's shoulder
- D. Encouraging the mother to sleep for 4 to 6 hours before interacting with the infant
Correct Answer: A
Rationale: The correct answer is A, having the mother feed the infant. This helps promote bonding through physical closeness, eye contact, and the release of oxytocin. Feeding also fosters a sense of responsibility and nurturing. Choice B may disrupt bonding by creating separation anxiety. Choice C is a comforting position but not as interactive as feeding. Choice D delays bonding and can impact the establishment of a strong maternal-infant relationship.
You may also like to solve these questions
Which finding in the assessment of a patient following an abruption placenta could indicate a major complication?
- A. Urine output of 30 mL in 1 hour
- B. Blood pressure of 110/60 mm Hg
- C. Bleeding at IV insertion site
- D. Respiratory rate of 16 breaths per minute
Correct Answer: C
Rationale: The correct answer is C because bleeding at the IV insertion site could indicate disseminated intravascular coagulation (DIC), a major complication of placental abruption. DIC is a serious condition that results in widespread clotting and bleeding throughout the body. This finding signifies that the patient's clotting factors are being consumed rapidly, leading to uncontrolled bleeding. Options A, B, and D are not indicative of a major complication of placental abruption. A decreased urine output, low blood pressure, and normal respiratory rate may be seen in various conditions but are not specific to DIC or a major complication in this context.
The labor nurse is admitting a patient in active labor with a history of genital herpes. On assessment, the patient reports a recent outbreak, and the nurse verifies lesions on the perineum. What is the nurse"™s next action?
- A. Ask the patient when she last had anything to eat or drink.
- B. Take a culture of the lesions to verify the involved organism.
- C. Ask the patient if she has had unprotected sex since her outbreak.
- D. Use electronic fetal surveillance to determine a baseline fetal heart rate.
Correct Answer: A
Rationale: The correct answer is A: Ask the patient when she last had anything to eat or drink. This is the correct action because the patient is in active labor with genital herpes lesions. Knowing the last time the patient had anything to eat or drink is essential in case an emergency cesarean section is needed, as the patient may need to be NPO.
Option B: Taking a culture of the lesions is not the immediate priority as the patient is in active labor and the presence of lesions is already confirmed.
Option C: Asking about unprotected sex is important for history taking but not the immediate next action in this scenario.
Option D: Using electronic fetal surveillance is also important, but the priority in this case is assessing the patient's fasting status for potential emergency procedures.
What is not a complication associated with chronic hypertension during pregnancy?
- A. preeclampsia
- B. gestational diabetes
- C. fetal growth restriction
- D. polyhydramnios
Correct Answer: B
Rationale: The correct answer is B, gestational diabetes. Chronic hypertension in pregnancy can lead to preeclampsia, fetal growth restriction, and polyhydramnios due to placental dysfunction and impaired blood flow. Gestational diabetes, on the other hand, is a separate condition caused by insulin resistance during pregnancy. It is not directly related to chronic hypertension and its complications. Therefore, gestational diabetes is not a complication associated with chronic hypertension during pregnancy.
A patient with preeclampsia is admitted complaining of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs indicate
- A. gastrointestinal upset.
- B. effects of magnesium sulfate.
- C. anxiety caused by hospitalization.
- D. worsening disease and impending convulsion.
Correct Answer: D
Rationale: The correct answer is D because the symptoms described (headache, visual changes, epigastric pain) are classic signs of worsening preeclampsia, indicating impending eclampsia with seizures. This requires urgent intervention to prevent serious complications. Option A is incorrect as gastrointestinal upset does not typically present with these specific signs. Option B is incorrect as magnesium sulfate is used to prevent seizures in preeclampsia, not cause the symptoms described. Option C is incorrect as anxiety would not cause the specific symptoms mentioned. In summary, the signs described point towards worsening disease and the likelihood of impending convulsions, necessitating immediate medical attention.
An abortion when the fetus dies but is retained in the uterus is called
- A. inevitable.
- B. missed.
- C. incomplete.
- D. threatened.
Correct Answer: B
Rationale: The correct answer is B: missed. In a missed abortion, the fetus dies but is not expelled from the uterus. This can be diagnosed during an ultrasound when no fetal heartbeat is detected. The term "inevitable" (choice A) refers to an abortion that is in progress and cannot be stopped. "Incomplete" (choice C) refers to an abortion where some fetal or placental tissue remains in the uterus. "Threatened" (choice D) refers to vaginal bleeding in early pregnancy, with a viable pregnancy.