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The nurse is providing care to a patient who delivered a 3525-g infant 14 hours ago. The nurse palpates the fundus of the uterus as firm and at the umbilicus. What is the nurse’s priority action related to this finding?
- A. Inform the health care provider.
- B. Encourage the patient to urinat
- C. Massage the uterus to expel clots.
- D. Document the finding in the patient’s chart.
Correct Answer: D
Rationale: The correct answer is D: Document the finding in the patient’s chart. The fundus being firm and at the umbilicus indicates normal involution after delivery. Documenting this finding is essential for accurate assessment and continuity of care. Informing the health care provider (choice A) is not necessary as the finding is normal. Encouraging the patient to urinate (choice B) is important for postpartum care but not the priority in this situation. Massaging the uterus to expel clots (choice C) is not indicated as the fundus is already firm, indicating proper contraction.
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Which anticipatory guidance action by the nurse makes role transition to parenthood easier?
- A. Helps the new parents identify resources.
- B. Recommends employing babysitters frequently.
- C. Tells the parents about the realities of parenthoo
- D. Offers a home phone number and tells parents to call if they have a question.
Correct Answer: A
Rationale: The correct answer is A because helping new parents identify resources promotes a smoother role transition by providing support and guidance. This action empowers parents to access necessary services and assistance. Choice B is incorrect as frequent babysitting does not address the parents' transition needs. Choice C is incorrect because focusing on the negatives may increase anxiety. Choice D is incorrect as it lacks proactive support and guidance.
A mother asks the nurse to tell her about the responsiveness of neonates at birth. Which of the following answers is appropriate? Select one that doesn't apply.
- A. Babies have a poorly developed sense of smell until they are 2 months old.
- B. Babies respond to all forms of taste well
- C. but they prefer to eat sweet things like breast milk.
- D. Babies are especially sensitive to being touched and cuddled.
Correct Answer: A
Rationale: Newborns have limited senses initially but can distinguish tastes, enjoy touch, and have limited vision until around 3 months.
A client has given birth to a baby girl with a visible birth defect. Which of the following maternal responses would lead the nurse to suspect poor mother-infant bonding?
- A. The mother states,"I'm so tired. Please feed the baby in the nursery for me."
- B. The mother states,"Her eyes look like mine, but her chin is her Dad's."
- C. The mother says,"We have decided to name her Sarah after my mother."
- D. The mother says,"I breastfed her. I still need help swaddling her, though."
Correct Answer: A
Rationale: Avoidance of infant care suggests bonding issues.
A postpartum patient calls the clinic and reports to the nurse feelings of fatigue, tearfulness, and anxiety. What is the nurse’s most appropriate response at this time?
- A. “When did these symptoms begin?”
- B. “Sounds like normal postpartum depression.”
- C. “Are you having trouble getting enough sleep?”
- D. “Are you able to get out of bed and provide care for your baby?”
Correct Answer: A
Rationale: The correct answer is A: "When did these symptoms begin?" The nurse's response should address the patient's concerns and gather more information to assess the situation accurately. By asking when the symptoms began, the nurse can determine the duration and severity of the symptoms, enabling appropriate intervention.
Choice B is incorrect because assuming the symptoms are due to "normal postpartum depression" without further assessment is premature and may overlook other potential causes. Choice C focuses solely on sleep and may not address the underlying issues causing the patient's symptoms. Choice D assumes the patient's ability to provide care for the baby without first addressing the patient's emotional well-being.
A nurse is advising a mother of a neonate being discharged from the hospital regarding car seat safety. Which of the following should be included in the teaching plan? Select all that apply.
- A. Place the baby's car seat in the front passenger seat.
- B. Position the car seat rear facing until the baby reaches two years of age.
- C. Attach the car seat to the car at 2 latch points at the base of the car seat.
- D. Check that the installed car seat moves no more than 1 inch side to side or front to back.
Correct Answer: B
Rationale: Rear-facing positioning and secure installation are critical for safety.