Nokea
The nurse is caring for the client who just gave birth. Which observation of the client should lead the nurse to be concerned about the client’s attachment to her male infant?
- A. Asking the caregiver about how to change his diaper
- B. Comparing her newborn’s nose to her brother’s nose
- C. Calling the baby “Kelly,” which was the name selected
- D. Repeatedly telling her husband that she wanted a girl
Correct Answer: D
Rationale: Seeking information about infant care is a sign that the mother is developing attachment to her infant. Pointing out family traits or characteristics seen in the newborn is a sign that the mother is developing attachment. Calling the infant by name is a sign that the mother is developing attachment to her infant. Attachment is demonstrated by expressing satisfaction with a baby’s appearance and sex. Frequent expressions of dissatisfaction with the sex of the infant should be concerning and followed up.
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The nurse notifies the HCP after feeling a pulsating mass during the vaginal examination of a newly admitted full-term pregnant client. Which HCP order should the nurse question?
- A. Prepare for possible cesarean section.
- B. Place the client in a knee-chest position.
- C. Initiate a low-dose oxytocin IV infusion.
- D. Give terbutaline 0.25 mg subcutaneously.
Correct Answer: C
Rationale: The nurse should question the administration of oxytocin (Pitocin). Oxytocin is used for stimulating contraction of the uterus. Uterine contractions can cause further umbilical cord compression. The pulsating mass indicates umbilical cord prolapse, which is a medical emergency. If vaginal birth is not imminent, a cesarean section is preferred in order to prevent hypoxic acidosis. Placing the client in a knee-chest position relieves pressure on the umbilical cord. Terbutaline (Brethine) is a tocolytic agent used to reduce contractions.
The nurse instructs the client to report which newborn symptom immediately?
- A. Mild jaundice on day 3
- B. Inability to suck or feed
- C. Occasional sneezing
- D. Soft spot on head
Correct Answer: B
Rationale: Inability to suck or feed is a serious symptom that may indicate neurological or health issues, requiring immediate reporting.
The postpartum client, who is 24 hours post—vaginal birth and breastfeeding, asks the nurse when she can begin exercising to regain her prepregnancy body shape. Which response by the nurse is correct?
- A. “Simple abdominal and pelvic exercises can begin right now.”
- B. “You will need to wait until after your 6-week postpartum checkup.”
- C. “Once your lochia has stopped, you can begin exercising.”
- D. “You should not exercise while you are breastfeeding.”
Correct Answer: A
Rationale: On the first postpartum day, the client should be taught to start abdominal breathing and pelvic rocking. Kegel exercises, which should have been taught during pregnancy, should be continued. Simple exercises should be added daily until, by 2 to 3 weeks postpartum, the mother should be able to do sit-ups and leg raises. Abdominal and pelvic exercises can begin right away and not wait for the 6-week postpartum checkup. There is no reason for the client to wait until the lochia has stopped before beginning exercises. There is no reason that a breastfeeding mother should not begin abdominal and pelvic exercises now.
The Caucasian postpartum client asks the nurse if the stretch marks (striae gravidarum) on her abdomen will ever go away. Which response by the nurse is most accurate?
- A. “Your stretch marks should totally disappear over the next month.”
- B. “Your stretch marks will always appear raised and reddened.”
- C. “Your stretch marks will lighten in color with good skin hydration.”
- D. “Your stretch marks will fade to pale white over the next 3 to 6 months.”
Correct Answer: D
Rationale: Stretch marks will fade but will not totally disappear. Stretch marks will fade and will not always appear reddened. There is no evidence that keeping the skin hydrated will lighten the appearance of the stretch marks. In Caucasian women, stretch marks will fade to a pale white over 3 to 6 months.
The nurse is taking the health history of the 40-year-old pregnant client. Which identified medical conditions increase the client’s risk for complications during her pregnancy? Select all that apply.
- A. Diabetes mellitus type 2
- B. Previous full-term pregnancy
- C. Controlled chronic hypertension
- D. New onset of iron-deficiency anemia
- E. Hemorrhage with a previous pregnancy
Correct Answer: A,C,D,E
Rationale: DM is a risk factor for complications such as preeclampsia, eclampsia, dystocia, fetal macrosomia, recurrent monilial vaginitis and UTIs, ketoacidosis, congenital abnormalities, and others. Controlled chronic hypertension may become uncontrolled during pregnancy due to water retention and other factors related to pregnancy. It is a risk factor for complications such as preeclampsia, placental abruption, and fetal hypoxia. Iron-deficiency anemia is associated with an increased incidence of preterm birth, low-birth-weight infants, and maternal and infant mortality. Previous pregnancy complications are a risk factor for complications. Having a previous full-term pregnancy is not a risk factor for a current pregnancy.