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. This action is performed prior to assessing the patient's uterus because a full bladder can displace the uterus, leading to inaccurate assessment of uterine size and position. By asking the patient to void, the nurse ensures an accurate assessment of the uterus. Placing the patient on the left side (choice A) is important for preventing supine hypotension but is not directly related to assessing the uterus. Assessing the passage of lochia (choice B) is important postpartum, but it can be done after checking the uterus. Administering a dose of oxytocin (choice D) may be indicated to prevent postpartum hemorrhage, but it is not the first step in assessing the patient's uterus.
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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.
In an attempt to improve the effectiveness of postpartum teaching, the nurse uses the AWHONN acronym POST BIRTH. Which teaching points require the patient to call for 911 assistance? Select all that apply.
- A. Bleeding that soaks a pad per hour
- B. A bad headache with vision changes
- C. Thoughts of hurting self or baby
- D. Signs an incision is not healing
Correct Answer: C
Rationale: The correct answer is C: Thoughts of hurting self or baby. This teaching point requires the patient to call for 911 assistance because it indicates a serious mental health emergency, such as postpartum depression or psychosis, which can lead to harm. It is crucial for immediate intervention by trained professionals.
A: Bleeding that soaks a pad per hour is concerning but does not necessarily require immediate 911 assistance unless accompanied by other severe symptoms like dizziness or fainting.
B: A bad headache with vision changes may indicate severe conditions like preeclampsia, which requires urgent medical attention but not necessarily a 911 call unless the symptoms worsen rapidly.
D: Signs an incision is not healing, while important to monitor, does not typically warrant a 911 call unless there are signs of infection or severe complications.
In summary, only choice C requires immediate 911 assistance due to the severe nature of mental health emergencies.
The postpartum nurse is planning a home visit to a mother who delivered her baby 1 week ago. Which finding indicates to the nurse a possible problem with mother–infant bonding?
- A. The mother is pleased to have the nurse visit her home and baby.
- B. The baby's grandmother is present and involved with mother/baby care.
- C. The mother focuses the visit on her physical recovery and concerns.
- D. The baby's father is on 'paternity leave' and involved with the baby.
Correct Answer: C
Rationale: The correct answer is C. The mother focusing the visit on her physical recovery and concerns indicates a possible problem with mother-infant bonding. This is because bonding involves emotional connection and interaction between the mother and the baby, not just physical care. A mother who is solely focused on her physical recovery may not be engaging emotionally with her baby, which can impact bonding.
A: The mother being pleased to have the nurse visit her home and baby is a positive sign of engagement and interest in the baby's well-being.
B: The baby's grandmother being present and involved with mother/baby care is also a positive sign of family support and involvement, which can enhance bonding.
D: The baby's father being on 'paternity leave' and involved with the baby is also a positive sign of parental involvement, which is important for bonding.
In an attempt to improve the effectiveness of postpartum teaching, the nurse uses the AWHONN acronym POST BIRTH. Which teaching points require the patient to call for 911 assistance? Select all that apply.
- A. Bleeding that soaks a pad per hour
- B. A bad headache with vision changes
- C. Thoughts of hurting self or baby
- D. Signs an incision is not healing
Correct Answer: C
Rationale: The correct answer is C: Thoughts of hurting self or baby. This teaching point requires the patient to call for 911 assistance because it indicates a serious mental health emergency that needs immediate intervention to ensure the safety of the patient and the baby. Thoughts of harming oneself or the baby are signs of a potential crisis that requires urgent professional help.
Other choices:
A: Bleeding that soaks a pad per hour - This is a concerning sign but does not necessarily require 911 assistance unless it is accompanied by other severe symptoms.
B: A bad headache with vision changes - This could indicate a serious condition like preeclampsia, but it does not always require immediate 911 assistance unless it is severe and life-threatening.
D: Signs an incision is not healing - While this may require medical attention, it does not typically necessitate calling 911 unless there are signs of infection or severe complications.
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 typical neonatal behavior where babies turn their head and open their mouth to search for a nipple when their cheek is touched. This reflex indicates the baby's communication of hunger and readiness to feed. This behavior is innate and essential for the baby's survival. In contrast, choices A, B, and C do not specifically demonstrate neonatal communication. Choice A does not involve any active communication or response from the baby. Choice B relates to a sensitivity to external stimuli rather than intentional communication. Choice C describes behavior that may not necessarily indicate communication but rather a lack of interest or engagement.