Nokea
The nurse is caring for a client, G3 P2002, whose infant has been diagnosed with a treatable birth defect. Which of the following is an appropriate statement for the nurse to make?
- A. Thank goodness. It could have been untreatable.
- B. I'm so happy that you have other children who are healthy.
- C. These things happen. They are the will of God.
- D. It is appropriate for you to cry at a time like this.
Correct Answer: D
Rationale: Validation of emotions is supportive.
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Which short-term goal is appropriate for a full-term, breastfeeding neonate?
- A. The baby will regain birth weight by 4 weeks of age.
- B. The baby will sleep through the night by 4 weeks of age.
- C. The baby will stool every 2 to 3 hours by 1 week of age.
- D. The baby will urinate 6 to 10 times per day by 1 week of age.
Correct Answer: D
Rationale: Frequent urination indicates adequate hydration.
A breastfeeding mother mentions to the nurse that she has heard that babies sleep better at night if they are given a small amount of rice cereal in the evening. Which of the following comments by the nurse is appropriate?
- A. That is correct. The rice cereal takes longer for them to digest so they sleep better and longer.
- B. It is recommended that babies receive only breast milk for the first 4 to 6 months of their lives.
- C. It is too early for rice cereal
- D. but I would recommend giving apple sauce at 3 months of age and apple juice 1 month later.
Correct Answer: B
Rationale: Exclusive breastfeeding is recommended for the first 6 months.
Which of the following are nursing measures that can promote parent-infant bonding and attachment? (Select all that apply.)
- A. Provide comfort and ample time for rest.
- B. Keep the baby wrapped to avoid cold stress.
- C. Position the infant face to face with the mother.
- D. Point out the characteristics of the infant in a positive way.
Correct Answer: A
Rationale: Rationale:
A: Providing comfort and ample time for rest helps parents feel less stressed, promoting bonding.
B: Keeping the baby wrapped is important for warmth but does not directly impact bonding.
C: Positioning face to face can enhance bonding, but it is not a nursing measure.
D: Pointing out characteristics positively can boost parent's confidence but does not directly promote bonding.
The postpartum person asks for only warm drinks and food. How can the nurse support this cultural tradition?
- A. Explain that nurses do not have control over the food.
- B. Tell the person that cold fluids are better for recovery.
- C. Instruct the person to call the nurse to warm up food or drink.
- D. Educate the person on culture in the United States.
Correct Answer: C
Rationale: Rationale for Correct Answer (C): Instructing the person to call the nurse to warm up food or drink is the best way to support the cultural tradition of consuming warm drinks and food. This option respects the individual's cultural preferences and provides a practical solution to meet their needs without imposing personal opinions. By offering assistance in warming up the food or drink, the nurse acknowledges and honors the person's cultural background, promoting a culturally sensitive and patient-centered approach.
Summary of Incorrect Choices:
A: Explaining that nurses do not have control over the food dismisses the person's request and does not address the cultural tradition.
B: Telling the person that cold fluids are better for recovery disregards the cultural preference for warm drinks and food.
D: Educating the person on culture in the United States is not relevant to supporting their specific cultural tradition of consuming warm drinks and food.
The nurse is developing a plan of care for the patient’s fourth stage of labor. One nursing intervention is to promote bonding. Specifically, which nursing action will facilitate the bonding process?
- A. Encourage the patient to call the baby by his or her first name
- B. Stimulate the grasp reflex by placing the patient’s finger in the infant’s palm.
- C. Ask the patient if she wants her baby placed on her chest immediately after birth.
- D. Assess for familial characteristics and remark on the resemblance to the patient or the father
Correct Answer: C
Rationale: Rationale: Choice C is correct because immediate skin-to-skin contact promotes bonding by facilitating the release of oxytocin, the bonding hormone. This close physical contact also helps regulate the baby's temperature and promotes breastfeeding initiation. Choices A, B, and D do not directly facilitate bonding as effectively as immediate skin-to-skin contact. Encouraging the baby's name or assessing for familial characteristics may be important but do not have the same immediate bonding impact as skin-to-skin contact. Placing the patient's finger in the infant's palm may stimulate reflexes but does not directly promote bonding as effectively as skin-to-skin contact.