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The nurse is providing postpartum care for an adolescent mother and her family. Which factor is most important for the nurse to consider when planning teaching about neonatal care?
- A. The grandparents decided they want to be involved.
- B. The parents need to discuss their expectations of each other.
- C. The mother is determined the father should be involved.
- D. Information must be presented on an age-appropriate level.
Correct Answer: D
Rationale: The correct answer is D: Information must be presented on an age-appropriate level. This is crucial as adolescents may have limited knowledge and understanding of neonatal care. Teaching in a way they can comprehend ensures effective learning.
Incorrect choices:
A: The involvement of grandparents is important but not the most critical factor.
B: Parental expectations are significant, but not directly related to neonatal care teaching.
C: The father's involvement is valuable, but not the primary consideration for teaching about neonatal care.
In summary, choosing answer D ensures effective communication and understanding for the adolescent mother and her family.
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The nurse is providing postpartum care for an adolescent mother and her family. Which factor is most important for the nurse to consider when planning teaching about neonatal care?
- A. The grandparents decided they want to be involved.
- B. The parents need to discuss their expectations of each other.
- C. The mother is determined the father should be involved.
- D. Information must be presented on an age-appropriate level.
Correct Answer: D
Rationale: The correct answer is D. It is crucial for the nurse to present information on neonatal care in an age-appropriate manner as the mother is an adolescent. This is important to ensure effective communication and understanding. Choice A does not directly impact the neonatal care teaching. Choice B focuses on the parents' expectations, not the neonatal care itself. Choice C emphasizes the father's involvement but does not address the approach to teaching the adolescent mother about neonatal care.
The nurse is performing a uterus assessment on a patient who is 20 hours postpartum. The nurse finds the fundus of the uterus to be soft and boggy. In addition, the uterus is displaced to the left and moderate bleeding is noted. If the uterus does respond to uterine massage, which actions does the nurse implement?
- A. Assist the patient to the bathroom to void.
- B. Reassess to determine response to treatment.
- C. Administer oxytocin as prescribed.
- D. Place an emergency call to the HCP.
Correct Answer: D
Rationale: The correct answer is D: Place an emergency call to the HCP. In this scenario, the patient is displaying signs of uterine atony, a condition where the uterus fails to contract properly postpartum, leading to excessive bleeding. The soft and boggy fundus, displacement to the left, and moderate bleeding indicate a serious issue that requires immediate medical attention. By calling the healthcare provider, the nurse can ensure timely intervention and treatment to address the uterine atony and prevent further complications. The other options are not appropriate at this time: A may worsen the situation by increasing bleeding, B delays necessary action, and C may be needed but not as the first priority in this critical situation.
A nurse is taking care of a G2P2 woman with a third-degree perineal tear during the fourth stage of labor. The nurse should include which intervention in the plan of care during her 12-hour shift?
- A. Assess vital signs every 4 hours.
- B. Keep patient NPO for first 12 hours.
- C. Catheterize patient prior to first ambulation.
- D. Prepare ice pack for application to perineal area.
Correct Answer: D
Rationale: The correct answer is D: Prepare ice pack for application to perineal area. This intervention is crucial for managing pain and reducing swelling in the perineal area post third-degree tear. Ice packs help vasoconstriction, decreasing blood flow and minimizing inflammation. It also provides comfort to the patient.
A: Assess vital signs every 4 hours - This is important but not the priority in this situation. Monitoring vital signs is essential, but immediate comfort measures should be prioritized for the patient with a perineal tear.
B: Keep patient NPO for first 12 hours - There is no indication to keep the patient NPO for 12 hours. Adequate hydration and nutrition are important for postpartum recovery.
C: Catheterize patient prior to first ambulation - Catheterization may not be necessary unless there are specific indications. It is not a routine intervention for a perineal tear during the fourth stage of labor.
The nurse is preparing a postpartum patient for discharge. Which patient teaching is most important for the nurse to provide?
- A. The signs and symptoms of uterine infection
- B. The signs and symptoms of secondary hemorrhage
- C. The signs and symptoms of postpartum depression
- D. The signs and symptoms of a boggy uterus
Correct Answer: B
Rationale: The correct answer is B: The signs and symptoms of secondary hemorrhage. This is the most important teaching because postpartum hemorrhage can be life-threatening and requires immediate medical attention. The other choices, while important, are not as urgent as secondary hemorrhage. A: Uterine infection signs and symptoms can develop gradually and usually do not pose an immediate threat. C: Postpartum depression is a serious concern but does not require immediate medical intervention. D: A boggy uterus can be a sign of uterine atony but does not necessarily indicate an emergency situation like secondary hemorrhage.
Which nursing care goal is the highest priority for a woman who had a vaginal delivery 3 hours earlier?
- A. The client will wear a well-supported bra.
- B. The client will eat 100% of her meals.
- C. The client will have a moderate lochia flow.
- D. The client will ambulate to the bathroom.
Correct Answer: C
Rationale: The correct answer is C: The client will have a moderate lochia flow. This is the highest priority goal because monitoring lochia flow post-vaginal delivery helps assess for excessive bleeding, which is crucial for preventing postpartum hemorrhage. Choice A is not a priority in the immediate postpartum period. Choice B is important but not as critical as monitoring lochia flow. Choice D is also important for preventing complications but not as urgent as assessing for postpartum bleeding.