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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 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.
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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 allows the nurse to gather valuable cultural information that may explain the mother's behavior of not holding the baby in an enface position. Understanding the family's beliefs helps the nurse provide culturally sensitive care.
A: "Can I help you with a nice position in which to hold your baby?" - This question assumes the mother needs help with positioning, which may not be the case. It does not address the underlying reason for the mother's behavior.
C: "Is there some reason that I have not seen you look into your baby's eyes?" - This question is accusatory and may make the mother defensive. It does not consider cultural reasons for the behavior.
D: "Your baby is so expressive, have you looked into his eyes yet?" - This question assumes the mother has not looked into the baby's eyes, which may not be the case. It does not address the cultural
The nurse is assessing her patient, who is 1 day postpartum. The nurse notes that the fundus is firm and at midline, the lochia is moderate in amount, and the presence of rubra with two dime-sized clots is on her peri-pad. What should the nurse determine from these assessment findings?
- A. They are normal.
- B. They indicate the presence of infection.
- C. The physician should be notified of the abnormal findings.
- D. The patient should be instructed to increase her fluid intake.
Correct Answer: A
Rationale: Step-by-step rationale for why choice A is correct:
1. Fundus is firm and at midline: Indicates normal involution of the uterus post-delivery.
2. Lochia is moderate with rubra and small clots: Expected findings in the early postpartum period.
3. Overall assessment findings within normal range: Indicate normal postpartum recovery.
Summary of why other choices are incorrect:
B. Presence of infection would usually be indicated by abnormal signs such as foul-smelling lochia or fever, which are absent in this case.
C. No abnormal findings are present that would necessitate physician notification.
D. Fluid intake is important postpartum, but there are no signs in this scenario indicating a need for increased fluid intake.
The nurse in a postpartum unit evaluates new parents for risk factors that can indicate problems with bonding/attachment. Which situations does the nurse NOT recognize as a cause for bonding/attachment problems?
- A. The mother experienced eclampsia in the third trimester of pregnancy.
- B. The neonate is being treated for meconium aspiration syndrome.
- C. The mother experienced dystocia in the second phase of labor.
- D. The father of the neonate is in the military and not yet home on leave.
Correct Answer: D
Rationale: The correct answer is D. The absence of the father due to military duty does not inherently cause bonding/attachment problems. Bonding issues are more commonly linked to factors like maternal health complications (choice A), neonatal health conditions (choice B), or labor complications (choice C). Military deployment may pose challenges, but it doesn't directly impede bonding. Therefore, option D is not a significant risk factor for bonding/attachment problems as compared to the other choices.
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 because general soreness is not a typical source of pain that postpartum patients experience. Uterine contractions, perineal trauma, and breast engorgement are common sources of pain in postpartum patients due to the physiological changes and processes associated with childbirth. General soreness is too vague and nonspecific to specifically assess for in this context. It is important for the nurse to focus on assessing and managing the more common sources of postpartum pain to provide effective care and support for the patient's recovery.
The nurse is researching for evidence-based practice related to a mother's response during the postpartum period. Based on research by Rubin and Mercer, which finding will the nurse be able to easily implement to change the culture of the unit?
- A. Satisfaction questionnaires
- B. Alterations in terminology
- C. Decrease nurse/patient ratios
- D. Soliciting paternal expectations
Correct Answer: B
Rationale: The correct answer is B: Alterations in terminology. Rubin and Mercer's research focuses on the importance of language and terminology used during the postpartum period. By implementing changes in the unit's terminology to be more supportive and empowering for mothers, the nurse can positively impact the culture of the unit. This can help create a more nurturing and understanding environment for new mothers.
Incorrect choices:
A: Satisfaction questionnaires are not directly related to changing the culture of the unit based on Rubin and Mercer's research.
C: Decreasing nurse/patient ratios may improve patient care but is not specifically mentioned in the research as a way to change the unit's culture.
D: Soliciting paternal expectations is not the focus of Rubin and Mercer's research, which is centered on the mother's response during the postpartum period.