Nokea
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: Correct Answer: B - Instruct the mother to void prior to the assessment.
Rationale:
1. Voiding before assessment prevents inaccurate findings due to bladder distension.
2. Empty bladder facilitates fundal assessment and reduces discomfort.
3. Ensures accurate assessment of postpartum lochia flow.
4. Promotes patient comfort and satisfaction.
Summary of Other Choices:
A - Massaging the fundus is important but should not be the initial step.
C - Assessing lochia flow is crucial, but voiding should be prioritized first.
D - Lowering the head of the bed is unnecessary and may cause discomfort.
You may also like to solve these questions
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: Step 1: The nurse examines the large collected clots to determine the presence of tissue.
Step 2: Presence of tissue may indicate retained placental fragments, which can lead to postpartum hemorrhage.
Step 3: Identifying tissue is crucial for proper management and prevention of complications.
Step 4: Validating clotting (Choice A) is important but not the primary reason for examining the clots.
Step 5: Obtaining an accurate description (Choice C) and documenting the number of clots (Choice D) are less critical compared to identifying tissue.
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.
The nurse is providing care for a new mother during a follow-up visit 6 weeks after a vaginal delivery. The mother begins to cry and reports difficulty with eating and sleeping. The nurse identifies postpartum blues and cites which reason as the most likely cause?
- A. Fatigue related to a 'fussy' baby
- B. Frustration over physical appearance
- C. Changes in hormonal levels
- D. Stress related to new mother role
Correct Answer: C
Rationale: Correct Answer: C - Changes in hormonal levels
Rationale:
1. Postpartum blues typically occur due to fluctuating hormone levels after childbirth.
2. Estrogen and progesterone levels drop significantly after delivery, leading to mood changes.
3. Symptoms like crying, difficulty eating, and sleeping align with hormonal imbalance postpartum.
Summary:
A: Fatigue related to a 'fussy' baby - Not directly related to hormonal changes causing postpartum blues.
B: Frustration over physical appearance - Not a primary cause of postpartum blues, which is more hormone-related.
D: Stress related to new mother role - While stress can contribute, hormonal changes are the primary cause.
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 encouraging the couple to identify mutual expectations of the fathering role promotes open communication and mutual understanding. This intervention fosters collaboration and unity in parenting. Choice B is incorrect because critiquing the father's methods may create tension and hinder his confidence. Choice C is incorrect because providing written materials alone may not address the unique dynamics of the couple's relationship. Choice D is incorrect as it focuses on potential conflict rather than fostering a positive and supportive environment for the father to identify his role.
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 because after a long labor, it is crucial for the woman to rest and recover. By reassuring her that it is okay to rest, the nurse acknowledges the importance of self-care for the mother's well-being, which ultimately benefits the baby. This response promotes maternal mental health and physical recovery, which are essential for successful breastfeeding and bonding with the baby.
Choice A is incorrect as it may create unnecessary guilt and pressure on the mother. Choice B is incorrect as the behavior described does not specifically align with the taking-hold stage. Choice C is incorrect as labeling the behavior as ineffective bonding/attachment without further assessment could be harmful and premature.