Nokea
The nurse is caring for a breastfeeding mother who asks advice on foods that will provide both vitamin A and iron. Which of the following should the nurse recommend?
- A. 1/2 cup raw celery dipped in 1 ounce cream cheese.
- B. 8 ounce yogurt mixed with 1 medium banana.
- C. 12 ounce strawberry milk shake.
- D. 1 1/2 cup raw broccoli.
Correct Answer: D
Rationale: Raw broccoli is a good source of vitamin A and iron, making it an ideal choice for the patient.
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An Asian client 's temperature 10 hours after delivery is 100.2°F, but when encouraged she refuses to drink her ice water. Which of the following nursing actions is most appropriate?
- A. Replace the ice water with hot water.
- B. Notify the client 's health care provider.
- C. Reassess the temperature in one half hour.
- D. Remind the client that drinking is very important.
Correct Answer: A
Rationale: Cultural preferences may influence responses to care. In some cultures, hot liquids are preferred, and providing hot water is culturally appropriate.
What theory developed by Ramona Mercer focused on the process of becoming a mother?
- A. Maternal Role Attainment
- B. Postpartum Adapting
- C. Postpartum Maternal Change
- D. Maternal Encouragement
Correct Answer: A
Rationale: Ramona Mercer's theory of Maternal Role Attainment focuses on how women adapt and assume the maternal role following childbirth.
A postpartum patient calls the clinic 4 days after the birth of her newborn because she is extremely tired and her vaginal bleeding is heavier. Which does the nurse anticipate when advising her to come in to the office right now?
- A. A hematocrit will be drawn, and the licensed provider will check for retained placental fragments.
- B. Her stress level and sleep deprivation will be evaluated, and a prescription for sleeping medication will be given.
- C. The perineum will be evaluated for lacerations that were missed.
- D. Reassure the client that this is all normal and provide a prescription for slow-release iron tablets.
Correct Answer: A
Rationale: The correct answer is A. The nurse anticipates that a hematocrit will be drawn and the provider will check for retained placental fragments because heavy vaginal bleeding and extreme fatigue could indicate postpartum hemorrhage due to retained placental tissue. This is a serious complication that requires immediate medical attention to prevent further complications such as infection or hemorrhagic shock.
Choice B is incorrect because prescribing sleeping medication does not address the underlying cause of the symptoms. Choice C is incorrect because lacerations would typically have been evaluated and repaired during delivery, and would not likely be missed. Choice D is incorrect because reassuring the client without further evaluation could lead to potential serious consequences if the underlying issue of retained placental fragments is not addressed promptly.
The nurse reviews postpartum discharge instructions regarding sexual health. What information is important to review?
- A. Place nothing in the vagina for 4 -6 weeks.
- B. Pregnancy cannot occur until 3 months after birth.
- C. Sexual intercourse can resume after discharge from the facility.
- D. Postpartum persons do not have a need for sexual intimacy.
Correct Answer: A
Rationale: It is important to wait 4 -6 weeks before placing anything in the vagina to allow for physical recovery and reduce infection risk.
Nurses need to understand the basic definitions and incidence data regarding PPH. Which statement regarding this condition is most accurate?
- A. PPH is easy to recognize early; after all, the woman is bleeding.
- B. Traditionally, it takes more than 1000 ml of blood after vaginal birth and 2500 ml after cesarean birth to define the condition as PPH.
- C. If anything, nurses and physicians tend to overestimate the amount of blood loss.
- D. Traditionally, PPH has been classified as early PPH or late PPH with respect to birth.
Correct Answer: B
Rationale: The correct answer is B because it accurately defines the criteria for postpartum hemorrhage (PPH). PPH is traditionally defined as losing more than 1000 ml of blood after vaginal birth and 2500 ml after cesarean birth. This definition helps healthcare providers recognize and manage PPH effectively.
Now, let's analyze why the other choices are incorrect:
A: This statement is incorrect because PPH may not always be easy to recognize early based solely on visible bleeding. Other signs and symptoms, such as tachycardia and hypotension, also play a crucial role in identifying PPH.
C: This statement is incorrect because underestimating, rather than overestimating, the amount of blood loss in PPH can lead to delayed intervention and potentially worsen the patient's condition.
D: This statement is incorrect because PPH is not classified based on timing (early or late PPH), but rather on the amount of blood loss as defined in choice B.