Nokea
The nurse assesses the breasts. What is a warning sign?
- A. colostrum expressed
- B. nipple everted
- C. redness, pain, and heat
- D. filling with milk
Correct Answer: C
Rationale: The correct answer is C because redness, pain, and heat are warning signs of a possible breast infection or inflammation, such as mastitis. This indicates an abnormality that requires further assessment and intervention.
A: Colostrum expressed is a normal occurrence during pregnancy or after delivery and is not a warning sign.
B: Nipple everted is also a normal anatomical variation and not a warning sign.
D: Filling with milk is expected during lactation and not necessarily indicative of a problem.
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During which phase of maternal adjustment will the mother relinquish the baby of her fantasies and accept the real baby?
- A. Letting-go
- B. Taking-in
- C. Taking-on
- D. Taking-hold
Correct Answer: A
Rationale: The correct answer is A: Letting-go. During this phase, the mother transitions from idealized fantasies about her baby to accepting the reality of the infant. She lets go of unrealistic expectations and embraces the actual characteristics of her child. Choice B, Taking-in, refers to the mother focusing on her own needs post-birth. Choice C, Taking-on, involves the mother identifying with her new role. Choice D, Taking-hold, pertains to the mother forming a strong bond with the baby. However, none of these phases specifically address the process of relinquishing idealized fantasies and accepting the real baby like the Letting-go phase does.
Which of the following full-term babies requires immediate intervention?
- A. Baby with seesaw breathing.
- B. Baby with irregular breathing with 10-second apnea spells.
- C. Baby with coordinated thoracic and abdominal breathing.
- D. Baby with respiratory rate of 52.
Correct Answer: A
Rationale: Seesaw breathing indicates diaphragmatic dysfunction and requires urgent evaluation.
The nurse is caring for a postoperative cesarean client. The woman is obese and is an insulin-dependent diabetic. For which of the following complications should the nurse carefully monitor this client?
- A. Failed lactogenesis.
- B. Dysfunctional parenting.
- C. Wound dehiscence.
- D. Projectile vomiting.
Correct Answer: C
Rationale: Obesity and diabetes increase the risk of wound complications.
On admission to the labor and delivery suite, the nurse assesses the discharge needs of a primipara who will be discharged home 4 days after a cesarean delivery. Which of the following questions should the nurse ask the client?
- A. Have you ever had anesthesia before?
- B. Do you have any allergies?
- C. Do you scar easily?
- D. Are there many stairs in your home?
Correct Answer: D
Rationale: Home environment impacts recovery.
The nurse observes a patient on her first postpartum day sitting in bed while her newborn lies awake in the bassinet. Which action is most appropriate for the nurse to take at this time?
- A. Hand the baby to the woman.
- B. Explain “taking-in” to the woman.
- C. Offer to hand the baby to the woman.
- D. No action, because this situation is perfectly acceptabl
Correct Answer: B
Rationale: The correct answer is B: Explain "taking-in" to the woman. This action allows the nurse to educate the woman on the normal postpartum adjustment period. By explaining "taking-in," the nurse helps the woman understand her current need for rest and reflection without feeling guilty about not immediately attending to her newborn. This approach promotes bonding by reducing anxiety and enhancing the mother's confidence in her abilities.
Summary of other choices:
A: Hand the baby to the woman - This choice may not address the woman's emotional needs and understanding of her current state.
C: Offer to hand the baby to the woman - While offering is a good gesture, it may not address the underlying need for education and reassurance.
D: No action, because this situation is perfectly acceptable - Ignoring the opportunity to provide guidance and support may lead to confusion and insecurity for the woman.