Nokea
Two hours after delivery, the mother tells the nurse that she will be bottle feeding. She asks what she can do to prevent the terrible pain experienced when her milk came in with her last baby. Which response by the nurse is most appropriate?
- A. “Once you have recovered from the birth, I will help you bind your breasts.”
- B. “Engorgement is familial. If you had it with your last baby, it is inevitable.”
- C. “I can help you put on a supportive bra; wear one constantly for 1 to 2 weeks.”
- D. “Engorgement occurs right after birth; if you don’t have it yet, it won’t occur.”
Correct Answer: C
Rationale: In comparison studies between breast binders and bras, mothers using binders experienced more engorgement and discomfort. Engorgement is not familial and not inevitable in bottle-feeding mothers. Wearing a supportive, well-fitting bra within 6 hours after birth can suppress lactation. The bra should be worn continuously, except for showering, until lactation is suppressed (usually 7 to 14 days). Signs of engorgement usually occur on the third to fifth postpartum day (not right after birth), and engorgement will spontaneously resolve by the tenth day postpartum.
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The nurse receives report for four postpartum clients. In which order should the nurse assess the clients? Prioritize the clients in order from first to last.
- A. The client who had a normal, spontaneous vaginal delivery 30 minutes ago.
- B. The client who had a cesarean section 48 hours ago and is bottle feeding her newborn infant.
- C. The client who had a vaginal delivery 32 hours ago and is having difficulty breastfeeding.
- D. The client who delivered her newborn via scheduled C-section 8 hours ago and has a PCA pump with morphine for pain control.
Correct Answer: A,D,C,B
Rationale: The client who had a normal, spontaneous vaginal delivery 30 minutes ago is priority. The first 2 hours after delivery is a time of transition, characterized by rapid changes in hemodynamic and physiological state for both the client and her newborn. The client who delivered her newborn via scheduled C-section 8 hours ago and has a PCA pump with morphine for pain control should be assessed next. Although she is 8 hours postpartum and probably stable, she is receiving morphine, and her respiratory status should be monitored Drag and Droply. The client who had a vaginal delivery 32 hours ago and is having difficulty breastfeeding should be assessed next. Newborn infants should successfully breastfeed every 2—3 hours. Failing to breastfeed with adequate amount and frequency may lead to newborn complications such as excessive weight loss and jaundice. The client who had a cesarean section 48 hours ago and is bottle feeding her newborn infant should be seen last; there is nothing indicating urgency.
The nurse instructs the client with hyperemesis gravidarum to avoid which trigger?
- A. Eating small, frequent meals
- B. Strong odors
- C. High-protein foods
- D. Adequate hydration
Correct Answer: B
Rationale: Strong odors can exacerbate nausea and vomiting in hyperemesis gravidarum, worsening symptoms.
The client in active labor has moderate to strong contractions occurring every 2 minutes and lasting 60 to 70 seconds. The client states extreme pain in the small of her back. Her abdomen reveals a small depression under the umbilicus. Which fetal position should the nurse document?
- A. Occiput anterior
- B. Occiput posterior
- C. Left occiput anterior
- D. Right occiput anterior
Correct Answer: B
Rationale: An occiput posterior position is characterized by intense back pain (back labor). A depression under the umbilicus occurs as a result of the posterior shoulder. When a fetus presents anterior, it is uncommon for the mother’s chief symptom to be back pain, and the uterus should appear smooth.
The nurse correctly instructs the client to contact the physician immediately under which circumstance?
- A. When the first fetal movement is felt
- B. If the breasts become tender
- C. If vaginal bleeding occurs
- D. When experiencing frequent urination
Correct Answer: C
Rationale: Vaginal bleeding is a danger sign in pregnancy, potentially indicating miscarriage or placental issues, requiring immediate reporting.
On the basis of this finding, the nurse can assume that the client is at least how many months' pregnant?
- A. 5 months
- B. 6 months
- C. 7 months
- D. 8 months
Correct Answer: A
Rationale: Ballottement, the rebound of the fetus when the cervix is tapped, is typically detectable around 4-5 months, indicating at least 5 months' gestation.