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The nurse educates the person with a newborn in the NICU. What guidance does the nurse provide?
- A. Breast milk is not good for a premature baby.
- B. Premature babies breast-feed easily.
- C. Skin-to-skin contact helps both baby and breast-feeding person.
- D. A bottle is recommended for all feedings.
Correct Answer: C
Rationale: Skin-to-skin contact enhances bonding promotes successful breastfeeding and stabilizes the baby's physiological status.
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A new father tells a nurse friend that his wife is agitated and acting in a bizarre fashion. She says that she hears voices. Her baby is 2 weeks old. The father is concerned about the care the mother is giving the baby. The nurse should:
- A. Tell the father that this is severe postpartum blues and will pass in a few days if he shows enough support.
- B. Suggest that the father try talking to his wife to find out what is bothering her about being a new mother.
- C. Explain that the mother will probably need psychotherapy and refer him to support groups.
- D. Tell the father to call the physician immediately and not to leave the woman alone with the baby.
Correct Answer: D
Rationale: The symptoms described may indicate postpartum psychosis a serious condition that requires immediate medical intervention to ensure the safety of both the mother and the baby.
The nurse assesses the fundus and finds it to be boggy, elevated >2 fingerbreadths above the umbilicus, and deviated to one side. What is the common cause of this finding?
- A. uterine rupture
- B. full bladder
- C. perineal laceration
- D. hematoma
Correct Answer: B
Rationale: A full bladder can displace the uterus and prevent it from contracting properly leading to a boggy fundus.
The nurse works in a labor and delivery facility with new protocols for estimating postpartum blood loss. Which method for estimating blood loss is implemented in the delivery room?
- A. Ask the patient how many peripads she considered to be “soaked.”
- B. Collect blood in calibrated, under-buttocks drapes for vaginal birth.
- C. Place a basin at the foot of the delivery table to catch any blood.
- D. Rely on the primary health care provider’s estimate of blood loss.
Correct Answer: B
Rationale: Collecting blood in calibrated, under-buttocks drapes for vaginal birth and then weighing the drapes is the easiest way to estimate blood loss in the delivery room.
What nursing diagnosis would be appropriate for the person with a coagulation disorder?
- A. risk for bleeding
- B. risk for fluid overload
- C. risk for breast-feeding failure
- D. risk for hypertension
Correct Answer: B
Rationale: Risk for bleeding is the main diagnosis in patients with coagulation disorders.
A client is receiving an epidural infusion of a narcotic for pain relief after a cesarean section. The nurse would report to the anesthesiologist if which of the following were assessed?
- A. Respiratory rate 8 rpm.
- B. Complaint of thirst.
- C. Urinary output of 250 mL/hr.
- D. Numbness of feet and ankles.
Correct Answer: A
Rationale: A respiratory rate of 8 breaths per minute indicates respiratory depression, which must be reported immediately as a potential complication of narcotic use.