Nokea
The community nurse is meeting a new mother for the first time. The client delivered her first child 5 days ago after a 12-hour labor. Neither the mother nor the infant had any complications during the birth or postpartum period. Which statement by the client would indicate to the nurse that the client is experiencing postpartum blues?
- A. One minute I'm laughing and the next I'm crying.
- B. My husband is helping out by changing the baby at night.
- C. Breastfeeding is going quite well now that the engorgement is gone.
- D. I am so happy and blessed to have my new baby.
Correct Answer: A
Rationale: Postpartum blues often manifest as mood swings, tearfulness, and irritability, which are common in the first few days after delivery.
You may also like to solve these questions
The nurse is performing the initial assessment of a newborn and notes retractions, nasal flaring, and tachypnea. The nurse will continue to perform a focused assessment on which system?
- A. Respiratory
- B. Cardiovascular
- C. Gastrointestinal
- D. Musculoskeletal
Correct Answer: A
Rationale: The correct answer is A: Respiratory. Retractions, nasal flaring, and tachypnea are signs of respiratory distress in a newborn. The nurse should focus on the respiratory system to assess the baby's breathing, lung sounds, oxygen saturation, and overall respiratory status. This is crucial for identifying any potential respiratory issues and providing prompt interventions.
Choices B, C, and D are incorrect because the symptoms described are specific to respiratory distress and do not indicate cardiovascular, gastrointestinal, or musculoskeletal issues. Focusing on these systems would not address the immediate concern of respiratory distress in the newborn.
The Apgar assessment tells the nurses and clinicians on the labor and delivery unit what information about the newborn?
- A. The Apgar assessment and score tells the team how the newborn is doing neurologically and physically after the birth.
- B. The Apgar assessment and score predicts the newborn's overall morbidity and mortality moving forward after birth.
- C. The Apgar assessment and score tells the team how the newborn is transitioning to the extrauterine world after birth.
- D. The Apgar assessment and score tells the team how the newborn handled the birth overall.
Correct Answer: C
Rationale: Rationale: The correct answer is C because the Apgar assessment and score specifically evaluate how well the newborn is transitioning to the outside world after birth. The Apgar score assesses the newborn's heart rate, respiratory effort, muscle tone, reflex irritability, and color. These parameters provide crucial information about the baby's initial adaptation to life outside the womb. Option A is incorrect because it oversimplifies the assessment by focusing only on neurological and physical aspects. Option B is incorrect because the Apgar score is not intended to predict long-term morbidity and mortality. Option D is incorrect as it does not encompass the full scope of the Apgar assessment, which is primarily concerned with the immediate transition of the newborn to extrauterine life.
In preparing a family for discharge from the perinatal unit, which method of nail care does the nurse teach as the preferred method?
- A. Cutting the nails with sharp scissors
- B. Filing the nails with a fine emery board
- C. Letting the nails break off naturally
- D. Wrapping the infant's hands in mittens
Correct Answer: B
Rationale: Several options exist for nail care to keep the infant from scratching her face. The nails can be cut, but there is a risk of damaging the delicate skin around the nail. This is best done while the baby sleeps. Letting the nails break off is not a good option, as the child may injure herself before they break. Covering the hands with mittens or a tee shirt is a possible option, but does not allow the child to suck on the fingers for self-soothing. The best option is to file the nails gently with a fine-grained emery board.
A home health nurse visits a 2-week-old infant and observes the umbilical cord has dried and fallen off. The area appears healed with no drainage or erythema present. Given these assessment findings, what instruction should the nurse give the parent?
- A. cover the umbilicus with a band-aid
- B. continue to clean the stump with alcohol for 1 week
- C. apply an antibiotic ointment to the stump
- D. give the baby a bath in an infant tub now
Correct Answer: D
Rationale: The correct answer is D: give the baby a bath in an infant tub now. This instruction is appropriate as the umbilical cord has dried and fallen off, indicating that the area is healed. Giving the baby a bath in an infant tub will help keep the area clean and promote healing.
A: Covering the umbilicus with a band-aid is unnecessary and may hinder air circulation, leading to potential infection.
B: Continuing to clean the stump with alcohol for 1 week is unnecessary as the cord has already fallen off and the area is healed.
C: Applying an antibiotic ointment to the stump is not recommended unless there are signs of infection, which are not present in this case.
The nurse determines the gestational age of an infant to be 40 weeks. Which characteristics are most likely to be observed? (Select all that apply.)
- A. Testes are pendulous, and the scrotum has deep rugae
- B. Plantar creases over entire sole
- C. Lanugo abundant over shoulders and back
- D. Vernix well distributed over entire body
Correct Answer: A
Rationale: Full-term infants typically exhibit pendulous testes, deep scrotal rugae, and plantar creases over the entire sole. Lanugo is usually minimal, and vernix tends to be localized rather than widespread.