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What symptom differentiates baby blues from PPD?
- A. Baby blues last longer than 14 days.
- B. Baby blues cause hallucinations.
- C. Baby blues occur in the first few days of the postpartum period.
- D. Baby blues are treated with inpatient therapy.
Correct Answer: A
Rationale: The correct answer is A: Baby blues last longer than 14 days. Baby blues typically resolve within 1-2 weeks postpartum. If symptoms persist for more than 14 days, it may indicate postpartum depression (PPD). Choice B is incorrect as hallucinations are not a common symptom of baby blues. Choice C is incorrect because baby blues can occur within the first few weeks postpartum, not just the first few days. Choice D is incorrect because baby blues are usually managed with support, counseling, and self-care, not inpatient therapy.
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The nurse suspects that her postpartum client is experiencing hemorrhagic shock. Which observation indicates or would confirm this diagnosis?
- A. Absence of cyanosis in the buccal mucosa
- B. Cool, dry skin
- C. Calm mental status
- D. Urinary output of at least 30 ml/hr
Correct Answer: D
Rationale: The correct answer is D because a urinary output of at least 30 ml/hr indicates adequate perfusion and kidney function, which is crucial in managing hemorrhagic shock. Low urine output is a sign of poor perfusion and impending organ failure. Absence of cyanosis in the buccal mucosa (choice A) is not specific to hemorrhagic shock. Cool, dry skin (choice B) is a late sign of shock. A calm mental status (choice C) can be seen in the compensatory stage of shock.
The nurse is caring for a Seventh Day Adventist woman who delivered a baby boy by cesarean section. Which of the following questions should be asked regarding this woman 's care?
- A. Would you like me to order a vegetarian clear liquid diet for you?
- B. Is there anything special you will need for your Sabbath on Sunday?
- C. Would you like to telephone your clergy to set up a date for the baptism?
- D. Will a rabbi be performing the circumcision on your baby?
Correct Answer: B
Rationale: Seventh Day Adventists observe the Sabbath on Saturday. The nurse should ask if special arrangements are needed for Sabbath observance.
A breastfeeding woman has been counseled on how to prevent engorgement. Which of the following actions by the mother shows that the teaching was effective?
- A. She pumps her breasts after each feeding.
- B. She feeds her baby every 2 to 3 hours.
- C. She feeds her baby 10 minutes on each side.
- D. She supplements each feeding with formula.
Correct Answer: B
Rationale: Feeding every 2-3 hours helps maintain milk production and prevents engorgement.
The nurse suspects that her postpartum client is experiencing hemorrhagic shock. Which observation indicates or would confirm this diagnosis?
- A. Absence of cyanosis in the buccal mucosa
- B. Cool, dry skin
- C. Calm mental status
- D. Urinary output of at least 30 ml/hr
Correct Answer: D
Rationale: Hemorrhagic shock is characterized by inadequate tissue perfusion due to severe blood loss, leading to decreased circulating volume. The body's compensatory mechanisms kick in to maintain blood pressure, causing the peripheral blood vessels to constrict. This constriction can lead to cool, clammy, and pale skin as the body shunts blood away from the skin's surface to the vital organs. The skin may also feel cool to the touch due to reduced perfusion. This observation is significant in indicating hemorrhagic shock because it signifies the body's response to the insufficient circulating volume and the need to prioritize perfusion to essential organs.
What nursing diagnosis would be appropriate for the person with a coagulation disorder?
- A. risk for bleeding
- B. risk for fluid overload
- C. risk for breast-feeding failure
- D. risk for hypertension
Correct Answer: B
Rationale: The correct answer is B: risk for fluid overload. A person with a coagulation disorder is at risk for excessive bleeding, which may lead to fluid overload due to blood loss and subsequent fluid replacement. This nursing diagnosis addresses the potential complications related to fluid imbalance in this population.
Incorrect choices:
A: risk for bleeding - While bleeding is a concern for someone with a coagulation disorder, this choice does not address the potential fluid overload that may result from excessive bleeding.
C: risk for breast-feeding failure - This choice is not relevant to the immediate health concerns of a person with a coagulation disorder.
D: risk for hypertension - Hypertension is not directly related to a coagulation disorder, therefore this choice is not appropriate as a nursing diagnosis in this context.