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The nurse is observing a new mother interact with her baby and notices the mother holding the baby close to her body. However, the nurse also notices that the mother does not hold the baby in an enface position. Which question is most appropriate for the nurse to ask?
- A. Can I help you with a nice position in which to hold your baby?'
- B. What can you tell me about your family's beliefs with new babies?'
- C. Is there some reason that I have not seen you look into your baby's eyes?'
- D. Your baby is so expressive, have you looked into his eyes yet?'
Correct Answer: B
Rationale: The correct answer is B: "What can you tell me about your family's beliefs with new babies?". This question is most appropriate as it opens up a dialogue about the mother's cultural or familial practices regarding infant care, which may explain why she is not holding the baby in an enface position. By asking about the family's beliefs, the nurse can gain insight into the mother's perspective and provide culturally sensitive care.
Choice A is incorrect as it assumes the mother needs help without considering her cultural background. Choice C is incorrect as it may come off as judgmental and accusatory. Choice D is incorrect as it focuses on the action of looking into the baby's eyes rather than understanding the cultural context behind the mother's behavior.
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The nurse is providing care to a patient who is postpartum. Using anatomy and physiology knowledge, which expectation does the nurse relate to the cardiovascular system?
- A. Patient reporting of being cold related to blood loss
- B. WBC laboratory level of 30,000/mm a few hours after delivery
- C. Risk for hemorrhage due to decrease in circulating clotting factors
- D. A normal postpartum hemoglobin laboratory value of less than 11 g/dL
Correct Answer: B
Rationale: The correct answer is B: WBC laboratory level of 30,000/mm a few hours after delivery. Postpartum, a temporary increase in white blood cells (WBCs) is normal due to the body's response to delivery and potential inflammation. This increase is known as leukocytosis and helps the body combat potential infections. The other choices are incorrect because: A is more related to hypovolemia than to cardiovascular changes. C is incorrect as clotting factors increase postpartum to reduce the risk of hemorrhage. D is incorrect as a hemoglobin level less than 11 g/dL postpartum may indicate anemia, not normalcy.
The nurse is providing care to a patient who is postpartum. Using anatomy and physiology knowledge, which expectation does the nurse relate to the cardiovascular system?
- A. Patient reporting of being cold related to blood loss
- B. WBC laboratory level of 30,000/mm a few hours after delivery
- C. Risk for hemorrhage due to decrease in circulating clotting factors
- D. A normal postpartum hemoglobin laboratory value of less than 11 g/dL
Correct Answer: B
Rationale: The correct answer is B. A postpartum WBC level of 30,000/mm is expected due to the physiological response to labor and delivery, known as leukocytosis. This is a normal finding as the body increases white blood cell production to fight off potential infections postpartum.
A: Patient feeling cold related to blood loss is more indicative of hypovolemia, a result of excessive blood loss, not a normal cardiovascular response postpartum.
C: Risk for hemorrhage due to decrease in clotting factors is incorrect as postpartum women actually have an increase in circulating clotting factors to prevent excessive bleeding.
D: A normal postpartum hemoglobin level of less than 11 g/dL is incorrect because a hemoglobin level below 11 g/dL would indicate anemia, not a normal postpartum finding.
A postpartum patient states, " am really in pain."For which sources of pain will the nurse not assess the patient?
- A. Uterine contractions
- B. Perineal trauma
- C. Breast engorgement
- D. General soreness
Correct Answer: D
Rationale: The correct answer is D: General soreness. Postpartum pain assessment typically focuses on specific sources such as uterine contractions, perineal trauma, and breast engorgement. General soreness is too vague and does not provide specific information for targeted intervention. By ruling out general soreness, the nurse can prioritize assessment and management of more specific sources of pain to provide appropriate care for the postpartum patient.
The nurse is observing a new mother interact with her baby and notices the mother holding the baby close to her body. However, the nurse also notices that the mother does not hold the baby in an enface position. Which question is most appropriate for the nurse to ask?
- A. Can I help you with a nice position in which to hold your baby?'
- B. What can you tell me about your family's beliefs with new babies?'
- C. Is there some reason that I have not seen you look into your baby's eyes?'
- D. Your baby is so expressive, have you looked into his eyes yet?'
Correct Answer: B
Rationale: The correct answer is B because it focuses on understanding the mother's cultural background and beliefs related to interacting with a new baby. This question allows the nurse to gain insight into the mother's perspective and approach to parenting, which can help tailor support and guidance effectively.
Choice A focuses on positioning, which is not the main concern in this scenario. Choice C assumes a negative reason for the mother's behavior without any evidence, potentially causing unnecessary worry. Choice D is too direct and may not be culturally sensitive, as some cultures have different norms regarding eye contact with infants.
Which best represents the process of postpartum diuresis in a postpartum client?
- A. A nervous response to vasomotor changes
- B. Elimination of excess fluid through the skin
- C. Underarm perspiration that occurs after ambulation
- D. Loss of fluid from expulsion of the placenta and amniotic fluid
Correct Answer: D
Rationale: The correct answer is D because postpartum diuresis occurs due to the loss of fluid from the expulsion of the placenta and amniotic fluid. This process helps the body eliminate excess fluid retained during pregnancy. A is incorrect as it refers to a nervous response, not a physiological process. B is incorrect as diuresis involves elimination through urine, not the skin. C is incorrect as underarm perspiration is not directly related to postpartum diuresis. In summary, D is the best representation as it directly links the process to the expulsion of placenta and amniotic fluid.