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Which nursing care goal is the highest priority for a woman who had a vaginal delivery 3 hours earlier?
- A. The client will wear a well-supported bra.
- B. The client will eat 100% of her meals.
- C. The client will have a moderate lochia flow.
- D. The client will ambulate to the bathroom.
Correct Answer: C
Rationale: The correct answer is C because monitoring lochia flow is crucial post-vaginal delivery to assess for excessive bleeding, which could indicate postpartum hemorrhage. This goal takes precedence over other options as it pertains to the client's immediate health and well-being. A: Wearing a bra does not address any urgent postpartum concerns. B: Eating meals is important but does not take priority over assessing for hemorrhage. D: Ambulation is beneficial but not as critical as monitoring lochia flow for potential complications.
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The nurse is aware that some parenting skills are acquired through the process of intentional learning. Which activity does the nurse associate with intentional learning?
- A. The couple observes other individuals who are mothers and fathers.
- B. The couple attends hospital classes addressing newborn and infant care.
- C. The couple discusses with each other how they were parented.
- D. The couple watches media containing parenting roles.
Correct Answer: B
Rationale: The correct answer is B because attending hospital classes on newborn and infant care involves intentional learning by actively seeking out information and skills related to parenting. The couple is proactively engaging in a structured learning environment to acquire knowledge and techniques essential for parenting.
A: Observing other individuals who are parents may provide some insight, but it is more passive and not as structured as intentional learning.
C: Discussing how they were parented is reflective, but it does not necessarily involve seeking out new information or skills actively.
D: Watching media containing parenting roles can provide some information passively, but it may not be as reliable or comprehensive as attending formal classes.
The nurse is providing education to a postpartum woman about exercises to strengthen the pelvis musculature. Which instruction should be included?
- A. "Ambulate three times a day."
- B. "Perform Kegel exercises."
- C. "Enroll in an aerobics class after discharge."
- D. "Do passive range-of-motion exercises while lying in bed."
Correct Answer: B
Rationale: The correct answer is B: "Perform Kegel exercises." Kegel exercises specifically target the pelvic floor muscles, which can help strengthen the pelvis musculature postpartum. This is important for improving pelvic floor support and preventing issues like urinary incontinence. Ambulating (A) is good for overall mobility but does not specifically target the pelvic muscles. Enrolling in an aerobics class (C) may be beneficial for overall fitness but does not address pelvic floor strengthening. Passive range-of-motion exercises (D) focus on joint flexibility rather than pelvic muscle strength.
The nurse is performing a uterus assessment on a patient who is 20 hours postpartum. The nurse finds the fundus of the uterus to be soft and boggy. In addition, the uterus is displaced to the left and moderate bleeding is noted. If the uterus does respond to uterine massage, which actions does the nurse implement?
- A. Assist the patient to the bathroom to void.
- B. Reassess to determine response to treatment.
- C. Administer oxytocin as prescribed.
- D. Place an emergency call to the HCP.
Correct Answer: D
Rationale: The correct answer is D: Place an emergency call to the HCP. In this scenario, the patient is displaying signs of uterine atony, a condition where the uterus fails to contract properly postpartum, leading to excessive bleeding. The soft and boggy fundus, displacement to the left, and moderate bleeding indicate a serious issue that requires immediate medical attention. By calling the healthcare provider, the nurse can ensure timely intervention and treatment to address the uterine atony and prevent further complications. The other options are not appropriate at this time: A may worsen the situation by increasing bleeding, B delays necessary action, and C may be needed but not as the first priority in this critical situation.
A postpartum patient comes to the clinic for her 6-week postpartum checkup. When assessing the patient's cervix, how should the nurse expect the cervix to appear?
- A. Noticeable small lacerations
- B. Approximately 3 cm dilated
- C. Symmetrically round external os
- D. Firm and thick
Correct Answer: C
Rationale: The correct answer is C: Symmetrically round external os. At 6 weeks postpartum, the cervix should have healed and returned to its pre-pregnancy state. The external os should appear symmetrically round, indicating proper healing and involution. A: Noticeable small lacerations would indicate incomplete healing. B: Approximately 3 cm dilated is not expected in a postpartum patient. D: Firm and thick would not be typical findings at 6 weeks postpartum.
The nurse is aware that some parenting skills are acquired through the process of intentional learning. Which activity does the nurse associate with intentional learning?
- A. The couple observes other individuals who are mothers and fathers.
- B. The couple attends hospital classes addressing newborn and infant care.
- C. The couple discusses with each other how they were parented.
- D. The couple watches media containing parenting roles.
Correct Answer: B
Rationale: The correct answer is B because attending hospital classes on newborn and infant care involves intentional learning, where the couple actively seeks out knowledge and skills related to parenting. This choice allows them to receive structured education and guidance from professionals in a focused setting. Observing other individuals (choice A) may provide some insights but lacks the structured learning environment. Discussing their own upbringing (choice C) may be informative but does not necessarily involve intentional learning focused on acquiring new parenting skills. Watching media (choice D) may offer some information but lacks the interactive and hands-on learning experience provided by attending hospital classes.