Nokea
The nurse is caring for a birth mother who is relinquishing her newborn. What intervention is appropriate for the nurse?
- A. Use words like 'giving away your child' or 'giving up for adoption.'
- B. Tell the person not to hold the baby.
- C. Ask the person why she is giving up her baby.
- D. Ask about the patient 's expectations for having newborn photos or video.
Correct Answer: D
Rationale: The nurse should support the person's emotional needs including helping with decision-making and documenting memories.
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A woman has an 8-lb, 9-oz baby after an 18-hour labor that required a vacuum extraction. Her membranes have been ruptured for 15 hours. Based on these facts, client teaching should emphasize:
- A. Reporting foul-smelling lochia and fever.
- B. Delaying intercourse for at least 6 weeks.
- C. Eating a diet that is high in iron and vitamin C.
- D. Losing weight over at least a 6-month period.
Correct Answer: A
Rationale: Prolonged rupture of membranes increases the risk of infectionand the woman should report any signs of infection such as foul-smelling lochia or fever.
The nurse suspects that her postpartum client is experiencing hemorrhagic shock. Which observation indicates or would confirm this diagnosis?
- A. Absence of cyanosis in the buccal mucosa
- B. Cool, dry skin
- C. Calm mental status
- D. Urinary output of at least 30 ml/hr
Correct Answer: D
Rationale: The correct answer is D because a urinary output of at least 30 ml/hr indicates adequate perfusion and kidney function, which is crucial in managing hemorrhagic shock. Low urine output is a sign of poor perfusion and impending organ failure. Absence of cyanosis in the buccal mucosa (choice A) is not specific to hemorrhagic shock. Cool, dry skin (choice B) is a late sign of shock. A calm mental status (choice C) can be seen in the compensatory stage of shock.
A woman, 24 hours postpartum, is complaining of profuse diaphoresis. She has no other complaints. Which of the following actions by the nurse is appropriate?
- A. Take the woman 's temperature.
- B. Advise the woman to decrease her fluid intake.
- C. Reassure the woman that this is normal.
- D. Notify the neonate 's pediatrician.
Correct Answer: C
Rationale: Profuse diaphoresis is a common and normal occurrence in the first 24 hours postpartum as the body works to eliminate excess fluid accumulated during pregnancy.
What symptom differentiates baby blues from PPD?
- A. Baby blues last longer than 14 days.
- B. Baby blues cause hallucinations.
- C. Baby blues occur in the first few days of the postpartum period.
- D. Baby blues are treated with inpatient therapy.
Correct Answer: A
Rationale: Baby blues typically last for a few days, while PPD lasts longer and includes more severe symptoms.
A client has just been transferred to the postpartum unit from labor and delivery. Which of the following tasks should the registered nurse delegate to the nursing care assistant?
- A. Assess client 's fundal height.
- B. Teach client how to massage her fundus.
- C. Take the client 's vital signs.
- D. Document quantity of lochia in the chart.
Correct Answer: C
Rationale: The nursing care assistant can take vital signs, while the registered nurse is responsible for more complex assessments like fundal height and teaching skills such as massaging the fundus.