Nokea
The nurse assesses a 2-day postpartum, breastfeeding client. The nurse notes blood on the mother's breast pad and a crack on the mother's nipple. Which of the following actions should the nurse perform at this time?
- A. Advise the woman to wash the area with soap to prevent mastitis.
- B. Provide the woman with a tube of topical lanolin.
- C. Remind the woman that the baby can become sick if he drinks the blood.
- D. Get the woman an order for a topical anesthetic.
Correct Answer: B
Rationale: Lanolin promotes healing.
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A postpartum patient asks, “Will these stretch marks ever go away?” Which is the nurse’s best response?
- A. “No, never.”
- B. “Yes, eventually.”
- C. “They will fade to silvery lines but won’t disappear completely.”
- D. “They will continue to fade and should be gone by your 6-week checkup.”
Correct Answer: C
Rationale: The correct answer is C: “They will fade to silvery lines but won’t disappear completely.” This response is the best because it provides a realistic expectation to the patient. Stretch marks may lighten over time but typically do not completely disappear. Choice A is incorrect as it provides a definitive and discouraging answer. Choice B is vague and does not offer a clear timeframe. Choice D is incorrect as it gives an overly optimistic timeline that may not be realistic for most individuals. Overall, choice C is the most accurate and supportive response for the patient's query.
A nurse is developing a teaching plan for parents who are taking home their 2-day-old breastfed baby. Which of the following should the nurse include in the plan?
- A. Wash hands well before picking up the baby.
- B. Refrain from having visitors for the first month.
- C. Wear a mask to prevent transmission of a cold.
- D. Sterilize the breast pump supplies after every use.
Correct Answer: A
Rationale: Hand hygiene is crucial to prevent infection.
Which of the following drawings is consistent with a baby who was in the frank breech position in utero?
- A. Drawing 1.
- B. Drawing 2.
- C. Drawing 3.
- D. Drawing 4.
Correct Answer: C
Rationale: Frank breech position involves flexed hips and extended knees.
A mother, G4 P4004, is 15 minutes postpartum. Her baby weighed 4,595 grams at birth. For which of the following complications should the nurse monitor this client?
- A. Seizures.
- B. Hemorrhage.
- C. Infection.
- D. Thrombosis.
Correct Answer: B
Rationale: Macrosomic babies increase the risk of postpartum hemorrhage.
Which description best explains the term reciprocal attachment behavior?
- A. Behavior during the sensitive period when the infant is in the quiet alert stage
- B. Positive feedback that the infant exhibits toward parents during the attachment process
- C. Unidirectional behavior exhibited by the infant, initiated and enhanced by eye contact
- D. Behavior by the infant during the sensitive period to elicit feelings of “falling in love” from the parents
Correct Answer: B
Rationale: The correct answer is B because reciprocal attachment behavior refers to the mutual and positive interactions between infants and their caregivers during the attachment process. This behavior involves the infant responding to the caregiver's actions with positive feedback, such as smiles, cooing, and seeking physical contact. This interaction strengthens the bond between the infant and caregiver.
Choice A is incorrect because it describes the infant's behavior during a specific stage (quiet alert stage) but does not capture the reciprocal nature of attachment behavior. Choice C is incorrect because reciprocal attachment behavior is not unidirectional and does not solely depend on eye contact. Choice D is incorrect because reciprocal attachment behavior is not about eliciting specific feelings from the parents but rather about building a strong, mutual bond between the infant and caregiver.