Nokea
The nurse takes a newborn to a primipara for a feeding. The mother holds the baby en face, strokes his cheek, and states that this is the first newborn she has ever held. Which of the following nursing assessments is most appropriate?
- A. Positive bonding and client needs little teaching.
- B. Positive bonding but teaching related to newborn care is needed.
- C. Poor bonding and referral to a child abuse agency is essential.
- D. Poor bonding but there is potential for positive mothering.
Correct Answer: B
Rationale: The mother is engaging with the baby, indicating positive bonding, but further teaching on newborn care is still necessary.
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A new father tells a nurse friend that his wife is agitated and acting in a bizarre fashion. She says that she hears voices. Her baby is 2 weeks old. The father is concerned about the care the mother is giving the baby. The nurse should:
- A. Tell the father that this is severe postpartum blues and will pass in a few days if he shows enough support.
- B. Suggest that the father try talking to his wife to find out what is bothering her about being a new mother.
- C. Explain that the mother will probably need psychotherapy and refer him to support groups.
- D. Tell the father to call the physician immediately and not to leave the woman alone with the baby.
Correct Answer: D
Rationale: The symptoms described may indicate postpartum psychosis a serious condition that requires immediate medical intervention to ensure the safety of both the mother and the baby.
What is a symptom of engorgement?
- A. protuberant nipples
- B. shiny, hard breast
- C. insufficient milk production
- D. soft, lumpy breast
Correct Answer: B
Rationale: Shiny, hard breasts are characteristic of engorgement.
The postpartum nurse notices that the last dose of IV Cefazolin is not running well. The patient’s IV site appears red, inflamed, and swollen. The patient states that the IV is tender and sore. What are the nurse’s next actions?
- A. Flush the IV with normal saline to improve the flow rate.
- B. Put the IV antibiotic on a pump for more accurate infusion of the correct dose.
- C. Remove the IV, restart it in a new location, and complete the antibiotic administration.
- D. Allow the IV to continue to drip slowly since it is her last dose.
Correct Answer: C
Rationale: The correct answer is C: Remove the IV, restart it in a new location, and complete the antibiotic administration. This is the correct action because the patient's IV site is showing signs of infection (redness, inflammation, swelling, tenderness). By removing the IV, the nurse can prevent the spread of infection and restart the antibiotic infusion in a new, sterile site to ensure proper treatment.
A: Flushing the IV with normal saline will not address the underlying issue of infection and may worsen the patient's condition.
B: Putting the IV antibiotic on a pump for more accurate infusion does not address the fact that the current IV site is infected and needs to be removed.
D: Allowing the IV to continue to drip slowly is not appropriate when the site is showing signs of infection.
The nurse informs a postpartum woman that which of the following is the reason ibuprofen (Advil) is especially effective for afterbirth pains?
- A. Ibuprofen is taken every two hours.
- B. Ibuprofen has an antiprostaglandin effect.
- C. Ibuprofen is given via the parenteral route.
- D. Ibuprofen can be administered in high doses.
Correct Answer: B
Rationale: Ibuprofen works by inhibiting prostaglandin production, which helps to reduce afterbirth pains.
The home health nurse visits a client who is 6 days postdelivery. The client appears sad, weeps frequently, and states, 'I don 't know what is wrong with me. I feel terrible. I should be happy, but I 'm not. ' Which of the following nursing diagnoses is appropriate for this client?
- A. Suicidal thoughts related to psychotic ideations.
- B. Post-trauma response related to traumatic delivery.
- C. Ineffective individual coping related to hormonal shifts.
- D. Spiritual distress related to immature belief systems.
Correct Answer: C
Rationale: The client 's symptoms suggest ineffective coping due to hormonal shifts commonly experienced during the postpartum period, possibly indicating postpartum blues.