NCLEX-RN
A primiparous client, who has just given birth to a healthy term neonate after 12 hours of labor, holds and looks at her neonate and begins to cry. The nurse interprets this behavior as a sign of which response? disappointment in the baby's gender grief over the ending of the pregnancy a normal response to the birth indication of postpartum "blues"
Childbirth is a very emotional experience. An expression of happiness with tears is a normal reaction. Cultural factors, exhaustion, and anxieties over the new role can all affect maternal responses, so the nurse must be sensitive to the client's emotional expressions. There is no evidence to suggest that the mother is disappointed in the baby's gender, grieving over the end of the pregnancy, or a candidate for postpartum "blues." However, approximately 80% of postpartum clients experience transient postpartum blues several days after birth.
A woman gave birth 1 hour ago to a full-term boy. The nurse's assessment reveals a well-contracted uterus that's midline, and at the level of the umbilicus. The client is bleeding heavily. What should the nurse do next? Firmly massage the uterus. Request an order for oxytocin. Assess for a distended bladder. Report the bleeding to the healthcare professional (HCP).
Heavy bleeding can signal uterine or vaginal lacerations. The nurse should report this finding to the HCP. Massaging a contracted uterus may cause uterine atony. The nurse should assess for a distended bladder if the uterus is soft or boggy. This client's uterus is contracted.
While the nurse is assessing the fundus of a multiparous client who gave birth 24 hours ago, the client asks, "What can I do to get rid of these stretch marks?" Which response would be most appropriate? "As long as you don not get pregnant again, the marks will disappear completely." "They usually fade to a silvery-white color over a period of time." "You will need to use a specially prescribed cream to help them disappear." "If you lose the weight you gained during pregnancy, the marks will fade to a pale pink."
Stretch marks, or striae gravidarum, are caused by stretching of the tissues, particularly over the abdomen. After birth, the tissues atrophy, leaving silver scars. These skin pigmentations will not disappear completely. The striae gravidarum may reappear as pink streaks if the client becomes pregnant again. Special creams are not warranted because they are not helpful and may be expensive. Weight loss does not make the marks disappear. Striae gravidarum tend to run in families.
A neonate has an imperforate anus, a tracheoesophageal fistula, and a single umbilical artery. What condition should the nurse suspect? Beckwith-Wiedemann syndrome trisomy 13 Turner's syndrome VATER association
VATER association involves a series of congenital anomalies including vertebral defects, an imperforate anus, tracheoesophageal fistula, a single umbilical artery, and renal dysplasia. Trisomy 13 and Turner's syndrome are chromosomal aberrations that don't occur with other defects. Beckwith-Wiedemann syndrome is a congenital growth disorder characterized by a large body size and large organs.
A neonate born by cesarean at 42 weeks' gestation, weighing 4.1 kg (9 lb), with Apgar scores of 8 at 1 minute and 9 at 5 minutes after birth, develops an increased respiratory rate and tremors of the hands and feet 2 hours postpartum. What is the priority problem for this neonate? ineffective airway clearance hyperthermia decreased cardiac output hypoglycemia
Increased respiratory rate and tremors are indicative of hypoglycemia, which commonly affects the postterm neonate because of depleted glycogen stores. There is no indication that the neonate has ineffective airway clearance, which would be evidenced by excessive amounts of mucus or visualization of meconium on the vocal cords. Lethargy, not tremors, would suggest infection or hyperthermia. Furthermore, the postterm neonate typically has difficulty maintaining temperature, resulting in hypothermia, not hyperthermia. Decreased cardiac output is not indicated, particularly because the neonate was born by cesarean section, which is not considered a difficult birth.
A multiparous client gives birth to dizygotic twins at 37 weeks' gestation. The twin neonates require additional hospitalization after the client is discharged. What is the most appropriate goal to include in the plan of care for the parents while the twins are hospitalized? Discuss how they will cope with twin infants at home. Participate in care of the twins as much as possible. Take turns providing 24-hour observation of the twins. Identify complications that may occur as the twins develop.
It is important that the parents be allowed to touch, hold, and participate in care of the twins whenever they desire. Ideally, this will be on a daily basis, to promote parent-infant bonding. It is not appropriate to discuss how the couple will cope with twin infants at home until they are ready to take the infants home. They are too overwhelmed at this point and are focused on the well-being of their infants while hospitalized. Having the couple visit the twins to provide care on a 24-hour basis is not warranted. Identifying complications that may occur is not appropriate. If complications arise, the parents should be well informed and given opportunities for discussion related to the care provided.
A woman who gave birth to a healthy baby 6 hours ago is having cramps in her legs. Upon further assessment, the nurse identifies leg pain on dorsiflexion. What action should the nurse take? Tell the woman to massage the area. Apply warm compresses to the area. Instruct the woman on how to do ankle pumps. Notify the health care provider (HCP).
The client is experiencing signs of thrombophlebitis. The nurse should notify the HCP because emboli formation is a potential risk. Massaging the area may cause the thrombus to dislocate and become an embolus. Warm compresses will increase circulation to the area and may precipitate embolus formation. Ankle pump exercises are helpful in preventing thrombophlebitis but will not prevent further risk of embolus formation at this time.
After teaching a primiparous client about treatment and self-care of infectious mastitis of the right breast, the nurse determines that the client needs further instruction when she makes which statement? "I can apply localized heat to the infected area." "I should increase my fluid intake to 2,000 mL/day." "I will need to take antibiotics for 7 to 10 days before I am cured." "I should begin breastfeeding on the right side to decrease the pain."
The client needs further instruction when she says that she should begin feeding on the right (painful) breast to decrease the pain. Starting the feeding on the unaffected (left) breast can stimulate the milk ejection reflex in the right breast and thereby decrease the pain. Frequent nursing or pumping is recommended to empty the breast. For some mothers, mastitis is so painful that they choose to discontinue breastfeeding, so these mothers need a great deal of support. Applying heat to the infected area before starting to feed is appropriate because heat stimulates circulation and promotes comfort. Increasing fluid intake is advised to ensure adequate hydration. Antibiotics need to be taken until all medication has been used, usually 7 to 10 days to ensure eradication of the infection.
