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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: The client will have a moderate lochia flow. This is the highest priority goal because monitoring lochia flow post-vaginal delivery helps assess for excessive bleeding, which is crucial for preventing postpartum hemorrhage. Choice A is not a priority in the immediate postpartum period. Choice B is important but not as critical as monitoring lochia flow. Choice D is also important for preventing complications but not as urgent as assessing for postpartum bleeding.
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The nurse is providing postpartum care for an adolescent mother and her family. Which factor is most important for the nurse to consider when planning teaching about neonatal care?
- A. The grandparents decided they want to be involved.
- B. The parents need to discuss their expectations of each other.
- C. The mother is determined the father should be involved.
- D. Information must be presented on an age-appropriate level.
Correct Answer: D
Rationale: The correct answer is D because presenting information on an age-appropriate level is crucial for effective teaching. Adolescents may have limited knowledge and experience, so tailoring the information to their level ensures understanding and compliance. Choice A focuses on grandparents' involvement, which is important but not the primary consideration. Choice B addresses parental expectations, which is relevant but not as critical as providing age-appropriate information. Choice C emphasizes the father's involvement, which is valuable but not the top priority compared to ensuring the information is understandable for the adolescent mother.
The nurse on a postpartum unit is acutely aware that cultural influences impact the patient's process of 'becoming a mother.' For which isn't a cultural influence does the nurse assess?
- A. What amount of time the mother spends in each phase
- B. Differences in the mother's expectation related to ability to rest
- C. How the mother physically recovers from labor and delivery
- D. Mother's involvement in decision making for the first few months
Correct Answer: C
Rationale: Rationale: The correct answer is C because physical recovery from labor and delivery is a biological process, not solely influenced by culture. Other choices (A, B, D) relate to cultural factors affecting the mother's transition to motherhood, such as rituals, beliefs, and social expectations. Cultural influence can affect the time spent in each phase, expectations related to rest, and decision-making processes. It is crucial for the nurse to assess these cultural influences to provide culturally competent care.
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 returned to its normal appearance, which is symmetrically round. This indicates proper healing and involution of the cervix after childbirth. Noticeable small lacerations (A) would suggest incomplete healing or trauma. Approximately 3 cm dilated (B) is not expected at 6 weeks postpartum as the cervix should be closed. Firm and thick (D) would indicate a cervix that has not undergone involution as expected by this time.
The nurse on a postpartum unit is acutely aware that cultural influences impact the patient's process of 'becoming a mother.' For which isn't a cultural influence does the nurse assess?
- A. What amount of time the mother spends in each phase
- B. Differences in the mother's expectation related to ability to rest
- C. How the mother physically recovers from labor and delivery
- D. Mother's involvement in decision making for the first few months
Correct Answer: C
Rationale: The correct answer is C because how a mother physically recovers from labor and delivery is primarily influenced by biological and physiological factors rather than cultural influences. The mother's physical recovery is guided by medical interventions, individual health conditions, and postpartum care practices. On the other hand, choices A, B, and D are all influenced by cultural factors. Choice A pertains to cultural variations in rituals or customs related to the duration of each phase of becoming a mother. Choice B involves cultural beliefs around postpartum rest and support systems. Choice D addresses cultural norms regarding maternal autonomy and decision-making in the early stages of motherhood.
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 findings of a soft, boggy fundus, left displacement, and moderate bleeding indicate uterine atony, a common cause of postpartum hemorrhage. If uterine massage doesn't improve the situation, immediate intervention is crucial. Calling the healthcare provider allows for rapid assessment and potential interventions like administering uterotonics or other necessary treatments to address the postpartum hemorrhage promptly. Choices A (assisting the patient to void) and C (administering oxytocin) are important interventions but not the priority in this critical situation. Choice B (reassessing) can delay necessary interventions for managing postpartum hemorrhage.