The nurse evaluates a postpartum couplet for parent-infant attachment. What finding would be concerning?
- A. The postpartum person is sleepy.
- B. Parents are both caring for the infant.
- C. The parent is disinterested in the infant.
- D. The family is involved.
Correct Answer: C
Rationale: The correct answer is C because parent-infant attachment involves emotional bonding and responsiveness. If a parent is disinterested, it may indicate a lack of bonding and potential attachment issues. Choice A is not concerning as sleepiness is common postpartum. Choice B is positive as both parents caring for the infant contributes to attachment. Choice D is also positive as family involvement can support attachment.
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A mother calls the nurse to her room because 'My baby's eyes are bleeding.' The nurse notes bright red hemorrhages in the sclerae of both of the baby's eyes. Which of the following actions by the nurse is appropriate at this time?
- A. Notify the pediatrician immediately and report the finding.
- B. Notify the social worker about the probable maternal abuse.
- C. Reassure the mother that the trauma resulted from pressure changes at birth and the hemorrhages will slowly disappear.
- D. Obtain an ophthalmoscope from the nursery to evaluate the red reflex and condition of the retina in each eye.
Correct Answer: C
Rationale: Subconjunctival hemorrhages are common and resolve spontaneously.
Using the Neonatal Infant Pain Scale (NIPS), a nurse is assessing the pain response of a newborn who has just had a circumcision. The nurse is assessing a change in which of the following signs/symptoms? Select all that apply.
- A. Heart rate.
- B. Blood pressure.
- C. Temperature.
- D. Facial expression.
Correct Answer: A
Rationale: Heart rate and facial expression are key indicators of neonatal pain.
The home health nurse is visiting a client with HIV who is 6 weeks postdelivery. Which of the following findings would indicate that patient teaching by the nurse in the hospital was successful?
- A. The client is breastfeeding her baby every two hours.
- B. The client is using a diaphragm for family planning.
- C. The client is taking her temperature every morning.
- D. The client is seeking care for a recent weight loss.
Correct Answer: D
Rationale: Weight loss may indicate opportunistic infection.
A woman is receiving Paxil (paroxetine) for postpartum depression. To prevent a drug/food interaction, the client must be advised to refrain from consuming which of the following?
- A. Alcohol.
- B. Grapefruit.
- C. Milk.
- D. Cabbage.
Correct Answer: B
Rationale: Grapefruit affects drug metabolism.
A woman who wishes to breastfeed advises the nurse that she had a breast reduction one year earlier. Which of the following responses by the nurse is appropriate?
- A. Advise the woman that unfortunately she will be unable to breastfeed.
- B. Examine the woman's breasts to see where the incision was placed.
- C. Monitor the baby's daily weights for excessive weight loss.
- D. Inform the woman that reduction surgery rarely affects milk transfer.
Correct Answer: C
Rationale: Weight monitoring ensures adequate milk transfer.