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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.
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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 differentiate between clots and actual tissue, which is crucial for identifying any potential complications postpartum. This step ensures accurate assessment and appropriate intervention if necessary.
Incorrect choices:
A: To validate the presence of clotting - This is not necessary as the presence of large clots already indicates clotting.
C: To obtain an accurate description - While important, the primary purpose of examining large clots in this context is to differentiate tissue from clots.
D: To document the number of clots - While documenting the number of clots is important, it is not the main reason for examining them in this scenario.
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 initial nursing intervention is to instruct the mother to void prior to the assessment (choice B). This is important as a full bladder can interfere with the accuracy of the fundal assessment. By ensuring the mother voids first, the nurse can accurately assess the fundus for any signs of excessive bleeding or abnormalities. This step is crucial in monitoring the postpartum patient's well-being.
Choice A is incorrect as massaging the fundus should come after assessing the lochia flow to prevent potential complications. Choice C is also incorrect as assessing the lochia flow should occur before massaging the fundus. Choice D is incorrect as lowering the head of the bed and having the mother lie flat is not necessary for a postpartum assessment.
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.
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 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.