Nokea
Which behavior does the nurse identify as a demonstration of unidirectional bonding between a parent and infant?
- A. The parents respond to the baby's cry.
- B. The parents call the baby by name.
- C. The baby responds to comforting measures.
- D. The parents stimulate and entertain the baby.
Correct Answer: B
Rationale: The correct answer is B because calling the baby by name demonstrates unidirectional bonding where the parent initiates the interaction without the need for the baby's response. This action shows a one-way connection from the parent to the infant. In contrast, choices A, C, and D involve mutual interaction between the parent and the baby, indicating bidirectional bonding where both parties are actively engaging with each other. Option A involves the parent responding to the baby's cry, option C involves the baby responding to comforting measures, and option D involves the parents stimulating and entertaining the baby, all of which require reciprocal actions from both the parent and the baby.
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The nurse is preparing to perform a visual assessment of the perineum of a postpartum patient. The nurse will use the REEDA acronym. Which specific assessments isn't covered by REEDA?
- A. Perineal coloration
- B. Suture line appearance
- C. Amount of swelling
- D. Description of pain
Correct Answer: D
Rationale: The correct answer is D, Description of pain. The REEDA acronym stands for Redness, Edema, Ecchymosis, Discharge, and Approximation. These components focus on physical aspects like inflammation, bruising, wound healing, and discharge. Pain assessment is important but not part of the REEDA acronym, which specifically addresses visible signs of perineal healing postpartum. A thorough assessment should include pain evaluation separately. Choices A, B, and C are incorrect because they are covered by the REEDA acronym, focusing on perineal coloration, suture line appearance, and amount of swelling, respectively.
The nurse in a postpartum unit frequently teaches patients regarding breast care. Which teaching is most helpful to the breastfeeding patient?
- A. Run warm water over breasts while in the shower.
- B. Wear a supportive bra for 24 hours a day.
- C. Express milk by a breast pump or manually.
- D. Take analgesics for breast pain management.
Correct Answer: C
Rationale: The correct answer is C because expressing milk by a breast pump or manually helps in relieving engorgement, preventing mastitis, and maintaining milk supply. This action also allows for proper milk removal and promotes breastfeeding success.
A: Running warm water over breasts can provide temporary relief but does not address the underlying issue of engorgement or milk expression.
B: Wearing a supportive bra is important, but doing so 24 hours a day can lead to discomfort and potential issues with milk supply and breast health.
D: Taking analgesics may provide pain relief but does not address the root cause of the issue and may mask potential problems.
A nurse is preparing to perform a fundal assessment on a postpartum client who delivered 12 hours ago. What should the nurse do first?
- A. Lower the head of the bed
- B. Locate the level of the fundus
- C. Assist the woman to the bathroom to empty her bladder
- D. Massage the fundus
Correct Answer: C
Rationale: The correct first step is to assist the woman to the bathroom to empty her bladder. This is important to ensure an accurate fundal assessment, as a full bladder can displace the uterus and lead to incorrect fundal height measurement. Lowering the head of the bed (Choice A) is not necessary for a fundal assessment. Locating the level of the fundus (Choice B) should come after ensuring the bladder is empty. Massaging the fundus (Choice D) is not indicated until after the fundal assessment is completed.
The nurse is counseling a lesbian couple who have decided to have a child. Which considerations doesn't the nurse present with regard to which partner will become pregnant?
- A. Consider the age and health of each partner.
- B. Evaluate each partner's career goals.
- C. Decide which partner has better insurance.
- D. Determine who will be on the birth certificate.
Correct Answer: D
Rationale: Correct Answer: D - Determine who will be on the birth certificate.
Rationale: The nurse should not present the consideration of who will be on the birth certificate because legal parentage can be determined through various means regardless of who gives birth. The birth certificate can be amended to include both partners, and legal agreements can be put in place to establish parental rights. Focusing on the birth certificate may limit the couple's options and overlook the importance of legal protections for both partners and the child.
Summary of Incorrect Choices:
A: Considering the age and health of each partner is important for making informed decisions about pregnancy but does not specifically address the issue of who will become pregnant.
B: Evaluating each partner's career goals is important for planning but is not directly related to the decision of who will carry the pregnancy.
C: Choosing based on insurance is a practical consideration but should not be the primary factor in deciding which partner will become pregnant as it does not address the complexities of parenthood and family dynamics
A multiparous patient reports severe uterine cramps the first day after a vaginal delivery. The nurse is aware the patient is breastfeeding and associates the patient's pain primarily with which occurrence?
- A. An increase in oxytocin release related to the newborn suckling
- B. The presence of intense afterbirth pains related to multiparity
- C. An expected response to the daily administration of oxytocin
- D. The efforts of the uterus to return to a prepregnancy condition
Correct Answer: A
Rationale: The correct answer is A: An increase in oxytocin release related to the newborn suckling. After delivery, breastfeeding stimulates the release of oxytocin, causing uterine contractions. This helps the uterus to contract, reduce bleeding, and return to its normal size. This process can result in uterine cramps, especially in multiparous women.
B: The presence of intense afterbirth pains related to multiparity - Afterbirth pains are common in multiparous women, but they are different from uterine cramps due to breastfeeding.
C: An expected response to the daily administration of oxytocin - The patient is breastfeeding, not receiving daily oxytocin administration.
D: The efforts of the uterus to return to a prepregnancy condition - While this is true, the primary reason for the uterine cramps in this scenario is the increased oxytocin release from breastfeeding.