Nokea
The nurse is teaching the Muslim client how to correctly latch her baby to her breast for breastfeeding. Two student nurses are observing the instruction. Later, the client requests that the nurse not be allowed to provide her postpartum care. What most likely caused the client to be uncomfortable with the nurse?
- A. Muslim women do not want to breastfeed while in the hospital.
- B. Muslim women wait for their milk to come in before they breastfeed.
- C. Muslim women are uncomfortable breastfeeding in public situations.
- D. Muslim women only breastfeed after the infant is given boiled water.
Correct Answer: C
Rationale: Korean mothers resist breastfeeding in the hospital. Some Asian women believe colostrum is “bad,” and therefore they do not feed until actual breast milk is present. Most Muslim women breastfeed because the Koran encourages it; however, they are uncomfortable about breastfeeding in public situations and prefer privacy. Having two students observing the feeding process most likely would make the client uncomfortable, as she would desire more privacy. Some Asian cultures believe the newborn must be given boiled water until the milk is actually present.
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The postpartum client is being discharged to home with a streptococcal puerperal infection. The client is taking antibiotics but asks the nurse what precautions she should take at home to prevent spreading the infection to her husband, newborn, and toddler. Which is the best response by the nurse?
- A. “No precautions are necessary since you are taking antibiotics.”
- B. “You should always wear a mask when caring for your newborn and toddler.”
- C. “Wash your hands before caring for your children and after toileting and perineal care.”
- D. “Your husband should provide all cares for both children until your infection is gone.”
Correct Answer: C
Rationale: The course of an endometrial infection is approximately 7 to 10 days, and thus standard precautions should be in place for that period of time even if the client has started antibiotics. Puerperal infections are not spread by droplets, and thus a mask is not necessary. Other than hand hygiene, no additional precautions need to be taken by the client in her home. The client is able to provide cares for her children, but hand washing is required before cares.
The client had a D&C for treating an incomplete spontaneous abortion. Which statements should the nurse include when preparing the client for discharge the same day? Select all that apply.
- A. “Return for a blood transfusion if bleeding continues to be dark red.”
- B. “Intravenous antibiotics will be prescribed every 8 hours for two days.”
- C. “I can make a referral to a pregnancy loss support group if you like.”
- D. “You need to use contraceptives to avoid getting pregnant for one year.”
- E. “Someone should remain with you at home for the first 12 to 24 hours.”
Correct Answer: C,E
Rationale: The client who had an incomplete spontaneous abortion may experience grief and loss. The nurse should offer to do a referral to a pregnancy loss support group to provide ongoing support after hospital discharge. A D&C is usually performed on an outpatient basis if there are no complications, and the client can return home a few hours after the procedure. Someone should remain with the client to ensure that she is safe and no complications develop. Dark red blood does not necessarily indicate the need for a blood transfusion; it could be old blood. The client should notify the HCP if experiencing heavy bleeding following the D&C. A D&C for treating incomplete spontaneous abortion does not require the routine administration of IV antibiotics. There is no medical need for the client who had a spontaneous abortion to avoid pregnancy for one year.
The postpartum client delivered a full-term infant 2 days previously. The client states to the nurse, “My breasts seem to be growing, and my bra no longer fits.” Which statement should be the basis for the nurse’s response to the client’s concern?
- A. Rapid enlargement of breasts usually is a symptom of infection.
- B. Increasing breast tissue may be a sign of postpartum fluid retention.
- C. Thrombi may form in veins of the breast and cause increased breast size.
- D. Breast tissue increases in the early postpartum period as milk forms.
Correct Answer: D
Rationale: Infection in the breast tissue results in flulike symptoms and redness and tenderness of the breast. It is usually unilateral and does not cause bilateral breast enlargement. Fluid is not retained during the postpartum period; rather, clients experience diuresis of the excess fluid volume accumulated during pregnancy. Fullness in both breasts would not be the result of thrombi formation. Symptoms of thrombi include redness, pain, and increased skin temperature over the thrombi. Breast tissue increases as breast milk forms, so a bra that was adequate during pregnancy may no longer be adequate by the second or third postpartum day.
The laboring multigravida client’s last vaginal examination was 8/90/+1. The client now states feeling rectal pressure. Which action should the nurse perform first?
- A. Encourage the client to push.
- B. Notify the obstetrician or midwife.
- C. Help the client to the bathroom.
- D. Complete another vaginal exam.
Correct Answer: D
Rationale: The nurse should first evaluate labor progress by performing another vaginal exam. Previously the client was almost fully effaced (90%), and fetal station was 1 cm below the ischial spines (+1). Rectal pressure is often due to pressure exerted during descent of the fetal presenting part. The client needs to be fully dilated (10 cm, not 8 cm) and fully effaced (100%, not 90%) before being encouraged to push. Pushing too early may cause cervical edema and lacerations and may slow the labor process. Rectal pressure may indicate that the client has progressed since the last vaginal exam. Another vaginal exam should be performed before contacting the obstetrician or midwife. During labor, rectal pressure is usually not due to the need for a bowel movement because intestinal motility decreases.
Which assessment finding best represents a positive sign of pregnancy?
- A. Palpable fetal outline
- B. Blotchy tan facial skin
- C. Positive pregnancy test
- D. Fetal heartbeat
Correct Answer: D
Rationale: A fetal heartbeat, detected by Doppler or ultrasound, is a positive sign of pregnancy, as it directly confirms the presence of a living fetus.