Nokea
Which statement should alert the nurse to the possibility of ineffective bonding between mother and newborn?
- A. "My baby has my eyes."
- B. "No one in my family has that big of a nose."
- C. "Where did he get those long fingers?"
- D. "Is it normal for him to sleep so much?"
Correct Answer: C
Rationale: The correct answer is C because the statement "Where did he get those long fingers?" indicates a lack of recognition or acceptance of the newborn's physical features, which could be a sign of ineffective bonding. This statement suggests a disconnect between the mother and newborn. In contrast, choices A and B show recognition of shared physical traits, indicating a bond. Choice D, asking about the baby's sleep patterns, is a common concern for new parents and may not necessarily indicate ineffective bonding.
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Prior to discharge from the birthing center, the nurse informs the patient that she will receive vaccines for rubella, hepatitis B, pertussis, and influenza. For which reason does the nurse explain the need for the vaccinations?
- A. Discharge with a neonate is discouraged if the mother is not vaccinated.
- B. Vaccinating the mother will protect the neonate from serious illnesses.
- C. The mother's immune system has been suppressed during pregnancy.
- D. Vaccination is more easily accomplished while the mother is under medical care.
Correct Answer: B
Rationale: Step 1: Vaccinating the mother before discharge is important to protect the neonate.
Step 2: Maternal vaccines provide passive immunity to the newborn through transplacental transfer of antibodies.
Step 3: This protection is crucial as newborns have immature immune systems and are vulnerable to infections.
Step 4: Rubella, hepatitis B, pertussis, and influenza are serious illnesses that can be prevented through maternal immunization.
Step 5: Therefore, the correct answer is B as it aligns with the concept of maternal vaccination for the benefit of the neonate.
Summary:
A: Incorrect. Discharge is not based on the mother's vaccination status but on the overall health of both mother and neonate.
C: Incorrect. Pregnancy does not suppress the immune system to the extent that maternal vaccination is contraindicated.
D: Incorrect. Vaccination is recommended based on the timing of administration, not solely on the mother's medical care status.
The nurse is providing postpartum care to a patient 24 hours after a vaginal delivery. Which action does the nurse perform prior to assessing the patient's uterus?
- A. Place the patient on the left side.
- B. Assess the passage of lochia.
- C. Ask the patient to void.
- D. Administer a dose of oxytocin.
Correct Answer: C
Rationale: The correct answer is C: Ask the patient to void. It is important to ask the patient to void before assessing the uterus to ensure that the bladder is empty, which allows for a more accurate assessment of the uterus size and position. This helps prevent displacement of the uterus due to a full bladder, leading to a more accurate assessment of postpartum hemorrhage risk. Placing the patient on the left side (A) is done after assessing the uterus to facilitate uterine involution. Assessing the passage of lochia (B) is important but not a priority before assessing the uterus. Administering oxytocin (D) may be indicated but should be based on assessment findings rather than being the first action.
The nurse is providing postpartum care to a patient 24 hours after a vaginal delivery. Which action does the nurse perform prior to assessing the patient's uterus?
- A. Place the patient on the left side.
- B. Assess the passage of lochia.
- C. Ask the patient to void.
- D. Administer a dose of oxytocin.
Correct Answer: C
Rationale: The correct answer is C: Ask the patient to void. This action is performed prior to assessing the patient's uterus because a full bladder can displace the uterus, leading to inaccurate assessment of uterine size and position. By asking the patient to void, the nurse ensures an accurate assessment of the uterus. Placing the patient on the left side (choice A) is important for preventing supine hypotension but is not directly related to assessing the uterus. Assessing the passage of lochia (choice B) is important postpartum, but it can be done after checking the uterus. Administering a dose of oxytocin (choice D) may be indicated to prevent postpartum hemorrhage, but it is not the first step in assessing the patient's uterus.
The postpartum nurse is planning a home visit to a mother who delivered her baby 1 week ago. Which finding indicates to the nurse a possible problem with mother–infant bonding?
- A. The mother is pleased to have the nurse visit her home and baby.
- B. The baby's grandmother is present and involved with mother/baby care.
- C. The mother focuses the visit on her physical recovery and concerns.
- D. The baby's father is on 'paternity leave' and involved with the baby.
Correct Answer: C
Rationale: The correct answer is C. The mother focusing the visit on her physical recovery and concerns indicates a possible problem with mother-infant bonding. This is because bonding involves emotional connection and interaction between the mother and the baby, not just physical care. A mother who is solely focused on her physical recovery may not be engaging emotionally with her baby, which can impact bonding.
A: The mother being pleased to have the nurse visit her home and baby is a positive sign of engagement and interest in the baby's well-being.
B: The baby's grandmother being present and involved with mother/baby care is also a positive sign of family support and involvement, which can enhance bonding.
D: The baby's father being on 'paternity leave' and involved with the baby is also a positive sign of parental involvement, which is important for bonding.
Which statement should alert the nurse to the possibility of ineffective bonding between mother and newborn?
- A. "My baby has my eyes."
- B. "No one in my family has that big of a nose."
- C. "Where did he get those long fingers?"
- D. "Is it normal for him to sleep so much?"
Correct Answer: C
Rationale: The correct answer is C because the statement "Where did he get those long fingers?" indicates a lack of recognition or acceptance of the newborn's physical traits, which could suggest a disconnect between the mother and infant. This statement may signal that the mother is not bonding effectively with the baby. In contrast, choices A, B, and D all demonstrate a degree of recognition or concern for the baby's physical characteristics or behaviors, which are more indicative of normal bonding behaviors between a mother and newborn.