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The nurse is collecting the urine of a postpartum patient who is passing large clots. For which reason does the nurse examine the large collected clots?
- A. To validate the presence of clotting
- B. To determine the presence of tissue
- C. To obtain an accurate description
- D. To document the number of clots
Correct Answer: B
Rationale: The correct answer is B: To determine the presence of tissue. By examining the large collected clots, the nurse can identify if there is any tissue present, which could indicate a potential complication like retained placental tissue. This is crucial for the patient's health and further management.
Incorrect choices:
A: To validate the presence of clotting - This is not the primary reason for examining the clots in this scenario.
C: To obtain an accurate description - While important, the main focus is on identifying tissue presence.
D: To document the number of clots - The primary concern is not the number of clots but rather the presence of tissue.
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A G1P1 has just experienced a 24-hour labor that included a 3-hour second stage. The woman states to the nurse, "I just can't feed my baby now. All I want to do is sleep." What is the appropriate response from the nurse?
- A. Discuss with the woman that the needs of her infant should come first
- B. Recognize this as a behavior of the taking-hold stage
- C. Record the behavior as ineffective bonding/attachment
- D. Reassure the woman that it is okay for her to rest at this time
Correct Answer: D
Rationale: The correct answer is D: Reassure the woman that it is okay for her to rest at this time.
Rationale:
1. The woman has just undergone a 24-hour labor with a 3-hour second stage, which is physically and emotionally exhausting.
2. It is important for the nurse to prioritize the woman's well-being and allow her to rest to recover.
3. Rest is crucial for the woman's recovery and ability to care for her baby effectively.
4. By reassuring her that it is okay to rest, the nurse promotes self-care and maternal well-being.
Other choices:
A: Discuss with the woman that the needs of her infant should come first - This is not the appropriate response as the woman's well-being should also be considered.
B: Recognize this as a behavior of the taking-hold stage - This is incorrect as the woman's exhaustion is likely due to the physically demanding labor.
C: Record the behavior as ineffective bonding/attachment - This is not appropriate
The nurse on a postpartum unit focuses on how to assist the father in identifying his role with the neonate. Which intervention by the nurse is most helpful?
- A. Encourage the couple to identify mutual expectations of the fathering role.
- B. Critique the father's methods of providing physical care for the neonate.
- C. Provide written materials about the physical and emotional role of a father.
- D. Observe for a competitive attitude between the parents about providing baby care.
Correct Answer: A
Rationale: The correct answer is A because it fosters open communication between the couple, allowing them to discuss and align their expectations regarding the father's role with the newborn. This intervention promotes mutual understanding and collaboration, which are crucial for successful parenting.
Choice B is incorrect as critiquing the father's methods may be perceived as judgmental and could hinder his confidence in caring for the baby.
Choice C is also incorrect because providing written materials alone may not effectively address the unique needs and dynamics of the couple's relationship and may not encourage active involvement from the father.
Choice D is incorrect as it focuses on potential conflicts between the parents rather than facilitating a supportive and cooperative environment for the father to establish his role with the neonate.
As a result of the previously mentioned research study, the nurses in a postpartum facility will implement which evidence-based change?
- A. Continue to assess the level of fatigue for the mother during postpartum period.
- B. Assist fathers in recognizing and managing stress and depressive symptoms.
- C. Encourage the father to go home and rest while the mother is hospitalized.
- D. Promote strategies to decrease fatigue during both prenatal and postnatal periods.
Correct Answer: D
Rationale: The correct answer is D because promoting strategies to decrease fatigue during both prenatal and postnatal periods aligns with evidence-based practice to improve maternal health outcomes. This approach acknowledges the importance of preventive measures to address fatigue before and after childbirth. Option A focuses solely on assessing fatigue without addressing interventions to mitigate it. Option B, while relevant, does not directly impact maternal fatigue. Option C overlooks the father's role in supporting the mother and infant. In summary, option D is the most appropriate as it addresses fatigue proactively throughout the perinatal period.
The nurse is discussing contraception with a couple before discharge following the birth of a first child. The couple are uncertain about the method but are certain about avoiding pregnancy for at least 2 years. Which method does the nurse recommend?
- A. Emergency contraceptives
- B. Oral estrogen/progesterone pill
- C. Depo-Provera
- D. Natural family planning
Correct Answer: C
Rationale: The correct answer is C: Depo-Provera. The couple wants to avoid pregnancy for at least 2 years. Depo-Provera is a highly effective long-acting reversible contraceptive that only requires an injection every 3 months, providing reliable contraception for an extended period. It does not rely on daily adherence like the oral pill (B) or emergency contraceptives (A). Natural family planning (D) may not be the best choice for a couple wanting to avoid pregnancy with certainty for 2 years due to its reliance on tracking menstrual cycles and abstinence during fertile periods.
The nurse is preparing to do a morning assessment on a 24-hour postpartum patient. Which nursing intervention is most appropriate initially?
- A. Massage the fundus until it is firm.
- B. Instruct the mother to void prior to the assessment.
- C. Assess the lochia flow while massaging the fundus.
- D. Lower the head of the bed and have the mother lie flat.
Correct Answer: B
Rationale: The correct answer is B: Instruct the mother to void prior to the assessment. This is the most appropriate initial nursing intervention because a full bladder can impede proper assessment of the fundus and lochia flow. Voiding before assessment ensures accurate findings and reduces the risk of discomfort for the patient.
A: Massaging the fundus until it is firm is important but should not be the initial step as assessing the bladder status is crucial first.
C: Assessing the lochia flow while massaging the fundus is important but should come after ensuring the bladder is empty.
D: Lowering the head of the bed and having the mother lie flat does not address the immediate need to empty the bladder for accurate assessment.