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 and establishes a connection with the infant. This behavior shows a one-way flow of communication and emotional attachment from the parent to the infant. In contrast, choices A, C, and D involve reciprocal interactions or responses between the parent and infant, indicating bidirectional bonding where both parties are actively engaged in the relationship. Therefore, choices A, C, and D do not exemplify unidirectional bonding as in choice B.
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The nurse is educating a postpartum woman on how to prevent engorgement. Which action of the patient indicates effective learning?
- A. Breastfeeding the infant every 2 to 3 hours
- B. Avoiding using soap on the breast when bathing
- C. Drinking 8 to 10 glasses of water during the day
- D. Binding the breast with a towel or stretch bandage
Correct Answer: A
Rationale: The correct answer is A because breastfeeding the infant every 2 to 3 hours helps to empty the breasts regularly, preventing engorgement. This frequent breastfeeding stimulates milk production and prevents milk stasis. Choice B is incorrect as avoiding soap on the breast during bathing is unrelated to preventing engorgement. Choice C is also incorrect as hydration is important, but it does not directly prevent engorgement. Choice D is incorrect as binding the breast with a towel or stretch bandage can lead to further engorgement by restricting milk flow.
The nurse on a postpartum unit is focused on providing care that will assist the mother and father in making the transition to parenthood. For which reason does the nurse review the prenatal and labor records?
- A. Pregnancy and birth experiences, which can either enhance or impede the process of becoming a mother.
- B. Awareness of prenatal classes that will help identify and focus on learning needs of both parents.
- C. Identification of preexisting maternal conditions that may interfere with parenting transitions.
- D. Knowledge regarding questions and concerns the mother and father may have about neonate issues.
Correct Answer: A
Rationale: The correct answer is A because reviewing the prenatal and labor records allows the nurse to understand the pregnancy and birth experiences of the mother and father, which can significantly impact their transition to parenthood. By knowing the details of these experiences, the nurse can identify factors that may enhance or impede the process of becoming a mother and father. This information helps the nurse tailor their care and support to address specific needs and concerns of the new parents.
Choice B is incorrect because the focus of reviewing prenatal and labor records is not solely on identifying and focusing on learning needs from prenatal classes. Choice C is incorrect because while identifying preexisting maternal conditions is important for overall care, the primary focus in this scenario is on the transition to parenthood. Choice D is incorrect because the knowledge regarding neonate issues is not the main purpose of reviewing prenatal and labor records in this context.
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: Rationale for correct answer A:
1. Breastfeeding stimulates the release of oxytocin.
2. Oxytocin causes uterine contractions.
3. Uterine contractions help the uterus return to its pre-pregnancy size.
4. Severe uterine cramps post-delivery are likely due to increased oxytocin release from breastfeeding.
Summary of why other choices are incorrect:
B: Afterbirth pains are typically crampy, but the scenario specifies severe pain on the first day after delivery, which is more likely due to breastfeeding.
C: Daily administration of oxytocin would not lead to sudden severe cramps on the first day post-delivery.
D: Uterus shrinking back to prepregnancy size causes cramping, but the timing and severity described in the scenario point more towards oxytocin release from breastfeeding.
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 answer is C because assisting the woman to the bathroom to empty her bladder is the first step in a fundal assessment. A full bladder can displace the uterus and affect fundal height accuracy. Lowering the head of the bed (A) is not necessary for this assessment. Locating the level of the fundus (B) should come after ensuring the bladder is empty. Massaging the fundus (D) is not the initial step and could be harmful if the bladder is full.
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, expressing milk by a breast pump or manually. This is the most helpful teaching for a breastfeeding patient as it helps maintain milk supply, prevent engorgement, and relieve discomfort. Expressing milk also allows for flexibility in feeding schedules and helps store milk for later use.
A: Running warm water over breasts in the shower may provide temporary relief but does not address milk expression.
B: Wearing a supportive bra is important, but it is not necessary to wear it 24 hours a day.
D: Taking analgesics for breast pain management should not be the first line of treatment and does not address the root cause of the issue.