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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.
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In an attempt to improve the effectiveness of postpartum teaching, the nurse uses the AWHONN acronym POST BIRTH. Which teaching points require the patient to call for 911 assistance? Select all that apply.
- A. Bleeding that soaks a pad per hour
- B. A bad headache with vision changes
- C. Thoughts of hurting self or baby
- D. Signs an incision is not healing
Correct Answer: C
Rationale: The correct answer is C: Thoughts of hurting self or baby. This teaching point requires the patient to call for 911 assistance because it indicates a serious mental health emergency that needs immediate intervention to ensure the safety of the patient and the baby. Thoughts of harming oneself or the baby are signs of a potential crisis that requires urgent professional help.
Other choices:
A: Bleeding that soaks a pad per hour - This is a concerning sign but does not necessarily require 911 assistance unless it is accompanied by other severe symptoms.
B: A bad headache with vision changes - This could indicate a serious condition like preeclampsia, but it does not always require immediate 911 assistance unless it is severe and life-threatening.
D: Signs an incision is not healing - While this may require medical attention, it does not typically necessitate calling 911 unless there are signs of infection or severe complications.
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.
A new mother expresses frustration about how to know what her baby wants. The mother states, 'I don't know what I expect, but then, the baby doesn't know either.' Which situation does the nurse use as an example of neonate communication?
- A. The baby is content to lie still on the mother's abdomen.
- B. The baby is easily awakened if irritated by loud noises.
- C. The baby resists eye contact if bored or disinterested.
- D. The baby roots for the breast when the cheek is stroked.
Correct Answer: D
Rationale: The correct answer is D because rooting reflex is a clear example of neonate communication. When the baby's cheek is stroked, the baby turns its head in the direction of the touch, indicating a desire for feeding. This reflexive behavior demonstrates the baby's ability to communicate its needs for nourishment.
A: The baby being content to lie still on the mother's abdomen does not directly relate to communication.
B: Being easily awakened by loud noises is a sensory response but not specifically a form of communication.
C: Resisting eye contact if bored or disinterested involves more complex social cues and is not typically seen in neonatal communication.
In summary, choice D is correct as it directly involves a neonatal communication reflex, while the other choices do not demonstrate clear communication cues in the context of a newborn baby.
The physician has ordered the rubella vaccine to be given to a postpartum woman who is being discharged. Which should be included when providing education about the vaccine to the woman?
- A. Breastfeeding is contraindicated.
- B. The woman should avoid becoming pregnant after receiving the vaccine.
- C. The vaccine can safely be given to women with egg allergies.
- D. The woman must be separated from her infant for 24 hours after receiving the vaccine.
Correct Answer: B
Rationale: The correct answer is B because rubella vaccine is a live attenuated vaccine, which means it should not be given to pregnant women as it can potentially harm the fetus. Therefore, it is important for the postpartum woman to avoid becoming pregnant after receiving the vaccine to prevent any risks to future pregnancies.
Choice A is incorrect as breastfeeding is not contraindicated with the rubella vaccine. Choice C is incorrect because the rubella vaccine should not be given to individuals with severe egg allergies. Choice D is incorrect as there is no need for the woman to be separated from her infant after receiving the rubella vaccine.
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 characteristics, which may suggest a disconnect or lack of bonding between the mother and the baby. This statement does not show the mother identifying any physical traits of herself in the baby, unlike choices A and B. Choice D is a common concern among new parents and does not necessarily indicate ineffective bonding. In summary, choice C is correct as it demonstrates a potential lack of bonding based on the mother's statement about the baby's physical features, while the other choices do not indicate the same level of concern.