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The nurse is assessing her patient, who is 1 day postpartum. The nurse notes that the fundus is firm and at midline, the lochia is moderate in amount, and the presence of rubra with two dime-sized clots is on her peri-pad. What should the nurse determine from these assessment findings?
- A. They are normal.
- B. They indicate the presence of infection.
- C. The physician should be notified of the abnormal findings.
- D. The patient should be instructed to increase her fluid intake.
Correct Answer: A
Rationale: Rationale:
A: These assessment findings are normal for a patient 1 day postpartum. A firm, midline fundus indicates proper uterine involution. Moderate lochia is expected at this stage, and small clots are common.
B: There are no signs of infection present in the scenario, such as foul odor or abnormal color of lochia.
C: The findings are within the expected range for a patient 1 day postpartum, so there is no need to notify the physician.
D: Increasing fluid intake is always important postpartum, but it is not specifically indicated based on the assessment findings provided.
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The nurse is providing care to a patient who is postpartum. Using anatomy and physiology knowledge, which expectation does the nurse relate to the cardiovascular system?
- A. Patient reporting of being cold related to blood loss
- B. WBC laboratory level of 30,000/mm a few hours after delivery
- C. Risk for hemorrhage due to decrease in circulating clotting factors
- D. A normal postpartum hemoglobin laboratory value of less than 11 g/dL
Correct Answer: B
Rationale: Step 1: Postpartum patients may have an increased WBC count due to the stress of delivery.
Step 2: A WBC level of 30,000/mm postpartum indicates a normal physiological response.
Step 3: This increase helps the body fight potential infections post-delivery.
Step 4: Therefore, choice B is correct as it aligns with normal postpartum physiology.
Summary: Choices A, C, and D are incorrect as they do not directly relate to postpartum physiology. A is more related to thermoregulation, C is about clotting factors, and D is about hemoglobin levels which may vary postpartum.
The nurse is observing a new mother interact with her baby and notices the mother holding the baby close to her body. However, the nurse also notices that the mother does not hold the baby in an enface position. Which question is most appropriate for the nurse to ask?
- A. Can I help you with a nice position in which to hold your baby?'
- B. What can you tell me about your family's beliefs with new babies?'
- C. Is there some reason that I have not seen you look into your baby's eyes?'
- D. Your baby is so expressive, have you looked into his eyes yet?'
Correct Answer: B
Rationale: The correct answer is B: "What can you tell me about your family's beliefs with new babies?". This question is most appropriate as it opens up a dialogue about the mother's cultural or familial practices regarding infant care, which may explain why she is not holding the baby in an enface position. By asking about the family's beliefs, the nurse can gain insight into the mother's perspective and provide culturally sensitive care.
Choice A is incorrect as it assumes the mother needs help without considering her cultural background. Choice C is incorrect as it may come off as judgmental and accusatory. Choice D is incorrect as it focuses on the action of looking into the baby's eyes rather than understanding the cultural context behind the mother's behavior.
The nurse is providing care to a patient who is postpartum. Using anatomy and physiology knowledge, which expectation does the nurse relate to the cardiovascular system?
- A. Patient reporting of being cold related to blood loss
- B. WBC laboratory level of 30,000/mm a few hours after delivery
- C. Risk for hemorrhage due to decrease in circulating clotting factors
- D. A normal postpartum hemoglobin laboratory value of less than 11 g/dL
Correct Answer: B
Rationale: The correct answer is B: WBC laboratory level of 30,000/mm a few hours after delivery. Postpartum, a temporary increase in white blood cells (WBCs) is normal due to the body's response to delivery and potential inflammation. This increase is known as leukocytosis and helps the body combat potential infections. The other choices are incorrect because: A is more related to hypovolemia than to cardiovascular changes. C is incorrect as clotting factors increase postpartum to reduce the risk of hemorrhage. D is incorrect as a hemoglobin level less than 11 g/dL postpartum may indicate anemia, not normalcy.
The nurse is researching for evidence-based practice related to a mother's response during the postpartum period. Based on research by Rubin and Mercer, which finding will the nurse be able to easily implement to change the culture of the unit?
- A. Satisfaction questionnaires
- B. Alterations in terminology
- C. Decrease nurse/patient ratios
- D. Soliciting paternal expectations
Correct Answer: B
Rationale: The correct answer is B: Alterations in terminology. Rubin and Mercer's research emphasizes the importance of language in shaping postpartum experiences. By changing terminologies used in the unit to be more supportive and empowering, the nurse can easily implement this finding to positively change the culture. Satisfaction questionnaires (A) may not directly address cultural change. Decreasing nurse/patient ratios (C) may require significant resources and restructuring. Soliciting paternal expectations (D) focuses on a different aspect and may not directly impact unit culture.
The nurse is researching for evidence-based practice related to a mother's response during the postpartum period. Based on research by Rubin and Mercer, which finding will the nurse be able to easily implement to change the culture of the unit?
- A. Satisfaction questionnaires
- B. Alterations in terminology
- C. Decrease nurse/patient ratios
- D. Soliciting paternal expectations
Correct Answer: B
Rationale: The correct answer is B: Alterations in terminology. Rubin and Mercer's research focuses on the importance of language and terminology used during the postpartum period. By implementing changes in the unit's terminology to be more supportive and empowering for mothers, the nurse can positively impact the culture of the unit. This can help create a more nurturing and understanding environment for new mothers.
Incorrect choices:
A: Satisfaction questionnaires are not directly related to changing the culture of the unit based on Rubin and Mercer's research.
C: Decreasing nurse/patient ratios may improve patient care but is not specifically mentioned in the research as a way to change the unit's culture.
D: Soliciting paternal expectations is not the focus of Rubin and Mercer's research, which is centered on the mother's response during the postpartum period.