Nokea
The nurse is caring for a woman of Middle Eastern descent on the first postpartum day. Education is provided regarding instruction on use of a sitz bath. What documentation best indicates that the woman has understood the provided instruction?
- A. Patient correctly performed return demonstration.
- B. Patient indicated understanding by nodding head with instruction.
- C. Patient verbalizes 'I understand.'
- D. Family member indicates patient understands procedure.
Correct Answer: A
Rationale: The nurse may need an interpreter to understand and provide optimal care to the woman and her family. A return demonstration is the most reliable indicator of understanding, especially considering cultural nuances where nodding may reflect courtesy rather than comprehension.
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What statement made by a new mother indicates she needs additional information about breastfeeding?
- A. I let the baby nurse 10 to 15 minutes on the first breast and then switch to the other breast.'
- B. The baby needs to nurse at least 5 minutes on the breast to get the hindmilk.'
- C. The baby has been nursing every 2 to 3 hours.'
- D. If the baby gets fussy between feedings, I give her a bottle of water.'
Correct Answer: D
Rationale: Supplemental feedings of formula or water should not be offered to a healthy newborn who is breastfeeding.
The nurse is counseling a lactating mother about diet. What would the nurse include with this information?
- A. Consume 500 more calories than her usual prepregnancy diet.
- B. Eat less meat and more fruits and vegetables.
- C. Drink 3 to 4 tall glasses of fluid daily.
- D. Eat 1000 more calories than her usual prepregnancy diet.
Correct Answer: A
Rationale: To maintain nutrient stores while breastfeeding, the mother needs 500 additional calories each day over her prepregnancy diet.
What type of lochia will the nurse assess initially after delivery?
- A. Serosa
- B. Rubra
- C. Alba
- D. Vaginalis
Correct Answer: B
Rationale: The initial vaginal discharge after delivery is called lochia rubra. It is red and moderately heavy. Lochia rubra lasts for up to 3 days postpartum.
What should the nurse implement for security purposes when bringing the infant from the nursery to the mother?
- A. Ask, 'Is this your band number?'
- B. Confirm room number of mother.
- C. Ask the mother to identify herself verbally.
- D. Check the band number of the infant with that of the mother.
Correct Answer: D
Rationale: The nurse should check the band number of the infant with that of the mother by asking the mother to verbally read the number.
After delivery, the nurse's assessment reveals a soft, boggy uterus located above the level of the umbilicus. What is the most appropriate nursing intervention?
- A. Notify the physician.
- B. Massage the fundus.
- C. Initiate measures that encourage voiding.
- D. Position the patient flat.
Correct Answer: B
Rationale: A poorly contracted uterus should be massaged until firm to prevent hemorrhage.