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 is important prior to assessing the patient's uterus because a full bladder can displace the uterus and make it difficult to accurately assess its position and firmness. By asking the patient to void, the nurse ensures a more accurate assessment of the uterus. Placing the patient on the left side (A) is a position used to maximize uterine perfusion but is not necessary prior to assessing the uterus. Assessing the passage of lochia (B) is important but can be done after assessing the uterus. Administering oxytocin (D) may be indicated to help prevent postpartum hemorrhage but is not necessary prior to assessing the uterus.
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Which statement should alert the nurse to the possibility of ineffective bonding between mother and newborn?
- A. "My baby has my eyes."
- B. "No one in my family has that big of a nose."
- C. "Where did he get those long fingers?"
- D. "Is it normal for him to sleep so much?"
Correct Answer: C
Rationale: The correct answer is C because the statement "Where did he get those long fingers?" indicates a lack of recognition or acceptance of the newborn's physical traits, which could suggest a disconnect between the mother and infant. This statement may signal that the mother is not bonding effectively with the baby. In contrast, choices A, B, and D all demonstrate a degree of recognition or concern for the baby's physical characteristics or behaviors, which are more indicative of normal bonding behaviors between a mother and newborn.
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.
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 classic example of neonate communication. When the baby's cheek is stroked, they turn their head in the direction of the touch in search of the breast for feeding. This reflex demonstrates the baby's ability to communicate their hunger needs. This action is instinctual and essential for the baby's survival.
Choices A, B, and C are incorrect because they do not directly relate to neonate communication. Choice A focuses on the baby's physical position rather than communication. Choice B mentions the baby's sensitivity to loud noises, which is more about sensory response than communication. Choice C refers to eye contact, which is not a typical form of communication for newborns.
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.
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-by-step rationale for why choice B is correct:
1. Vaccinating the mother will stimulate her immune system to produce antibodies against rubella, hepatitis B, pertussis, and influenza.
2. These antibodies can pass through the placenta to the neonate, providing passive immunity and protecting the baby from serious illnesses.
3. Newborns have immature immune systems, making them vulnerable to infections, so maternal vaccination is crucial.
4. This approach also helps protect the neonate during the early months when they are too young to receive vaccines themselves.
Summary of why the other choices are incorrect:
A. Discharge with a neonate is not contingent on the mother's vaccination status.
C. The mother's immune system is not necessarily suppressed during pregnancy; vaccination is still recommended.
D. Vaccination can be done post-discharge, but protecting the neonate is the primary reason for vaccinating the mother before discharge.