Nokea
The nurse is providing postpartum care to a patient 24 hours after a vaginal delivery. Which action does the nurse perform prior to assessing the patient's uterus?
- A. Place the patient on the left side.
- B. Assess the passage of lochia.
- C. Ask the patient to void.
- D. Administer a dose of oxytocin.
Correct Answer: C
Rationale: The correct answer is C: Ask the patient to void. It is important to ask the patient to void before assessing the uterus to ensure that the bladder is empty, which allows for a more accurate assessment of the uterus size and position. This helps prevent displacement of the uterus due to a full bladder, leading to a more accurate assessment of postpartum hemorrhage risk. Placing the patient on the left side (A) is done after assessing the uterus to facilitate uterine involution. Assessing the passage of lochia (B) is important but not a priority before assessing the uterus. Administering oxytocin (D) may be indicated but should be based on assessment findings rather than being the first action.
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The physician has ordered the rubella vaccine to be given to a postpartum woman who is being discharged. Which should be included when providing education about the vaccine to the woman?
- A. Breastfeeding is contraindicated.
- B. The woman should avoid becoming pregnant after receiving the vaccine.
- C. The vaccine can safely be given to women with egg allergies.
- D. The woman must be separated from her infant for 24 hours after receiving the vaccine.
Correct Answer: B
Rationale: The correct answer is B: The woman should avoid becoming pregnant after receiving the vaccine. This is because the rubella vaccine contains a live virus that could potentially harm a developing fetus if the woman were to become pregnant shortly after receiving the vaccine. It is recommended to wait at least 1 month after vaccination before trying to conceive.
Choice A is incorrect because breastfeeding is not contraindicated after receiving the rubella vaccine. Choice C is incorrect as women with severe egg allergies should not receive the rubella vaccine due to potential allergic reactions. Choice D is incorrect as there is no need for the woman to be separated from her infant after receiving the rubella vaccine.
A new mother expresses frustration about how to know what her baby wants. The mother states, 'I don't know what I expect, but then, the baby doesn't know either.' Which situation does the nurse use as an example of neonate communication?
- A. The baby is content to lie still on the mother's abdomen.
- B. The baby is easily awakened if irritated by loud noises.
- C. The baby resists eye contact if bored or disinterested.
- D. The baby roots for the breast when the cheek is stroked.
Correct Answer: D
Rationale: The correct answer is D because rooting reflex is a clear example of neonate communication. When the baby's cheek is stroked, the baby turns its head in the direction of the touch, indicating a desire for feeding. This reflexive behavior demonstrates the baby's ability to communicate its needs for nourishment.
A: The baby being content to lie still on the mother's abdomen does not directly relate to communication.
B: Being easily awakened by loud noises is a sensory response but not specifically a form of communication.
C: Resisting eye contact if bored or disinterested involves more complex social cues and is not typically seen in neonatal communication.
In summary, choice D is correct as it directly involves a neonatal communication reflex, while the other choices do not demonstrate clear communication cues in the context of a newborn baby.
The physician has ordered the rubella vaccine to be given to a postpartum woman who is being discharged. Which should be included when providing education about the vaccine to the woman?
- A. Breastfeeding is contraindicated.
- B. The woman should avoid becoming pregnant after receiving the vaccine.
- C. The vaccine can safely be given to women with egg allergies.
- D. The woman must be separated from her infant for 24 hours after receiving the vaccine.
Correct Answer: B
Rationale: The correct answer is B because rubella vaccine is a live attenuated vaccine, which means it should not be given to pregnant women as it can potentially harm the fetus. Therefore, it is important for the postpartum woman to avoid becoming pregnant after receiving the vaccine to prevent any risks to future pregnancies.
Choice A is incorrect as breastfeeding is not contraindicated with the rubella vaccine. Choice C is incorrect because the rubella vaccine should not be given to individuals with severe egg allergies. Choice D is incorrect as there is no need for the woman to be separated from her infant after receiving the rubella vaccine.
A nurse is providing postpartum care to a G4P4 woman who gave birth vaginally 48 hours ago to a 9 pound 10 ounce boy with only a pudendal block for anesthesia. The physician has written orders for the woman to have a sitz bath three times a day. Which information is most closely correlated with the order?
- A. The woman is multiparous.
- B. The woman has an episiotomy.
- C. The woman had a vaginal birth.
- D. The woman received a pudendal block for anesthesia.
Correct Answer: B
Rationale: The correct answer is B: The woman has an episiotomy. A sitz bath is often recommended postpartum for women who have had an episiotomy to promote healing and relieve discomfort. An episiotomy is a surgical incision made in the perineum during childbirth to facilitate delivery and prevent tearing. The warm water in a sitz bath helps to reduce swelling, promote circulation, and clean the area.
Incorrect choices:
A: The woman is multiparous - Multiparity does not directly correlate with the need for a sitz bath postpartum.
C: The woman had a vaginal birth - While this is true, it does not specifically address the need for a sitz bath.
D: The woman received a pudendal block for anesthesia - Although this information may be relevant to the birth experience, it does not directly relate to the need for a sitz bath postpartum.
Prior to discharge from the birthing center, the nurse informs the patient that she will receive vaccines for rubella, hepatitis B, pertussis, and influenza. For which reason does the nurse explain the need for the vaccinations?
- A. Discharge with a neonate is discouraged if the mother is not vaccinated.
- B. Vaccinating the mother will protect the neonate from serious illnesses.
- C. The mother's immune system has been suppressed during pregnancy.
- D. Vaccination is more easily accomplished while the mother is under medical care.
Correct Answer: B
Rationale: Step 1: Vaccinating the mother before discharge is important to protect the neonate.
Step 2: Maternal vaccines provide passive immunity to the newborn through transplacental transfer of antibodies.
Step 3: This protection is crucial as newborns have immature immune systems and are vulnerable to infections.
Step 4: Rubella, hepatitis B, pertussis, and influenza are serious illnesses that can be prevented through maternal immunization.
Step 5: Therefore, the correct answer is B as it aligns with the concept of maternal vaccination for the benefit of the neonate.
Summary:
A: Incorrect. Discharge is not based on the mother's vaccination status but on the overall health of both mother and neonate.
C: Incorrect. Pregnancy does not suppress the immune system to the extent that maternal vaccination is contraindicated.
D: Incorrect. Vaccination is recommended based on the timing of administration, not solely on the mother's medical care status.