Expanding Family and Community Practice Questions

Question 1. A nurse is caring for a patient 6 hours post-vaginal delivery of a term neonate. She notes a white blood cell count of 20,000/mm. What is the priority nursing intervention for this patient? 1. Notify the physician or midwife 2. Interpret as a normal finding 3. Administer Tylenol 1,000mg PO 4. Order a repeat CBC for the next morning Rationales Option 1: The physician or midwife does not need to be notified of this normal finding. Option 2: White blood cell levels may increase to 30,000/mm within a few hours of birth as the result of the stress of labor. Option 3: Tylenol is not warranted for an increased white blood cell count. Option 4: A CBC does not need to be repeated unless ordered by the provider. Question 2. A postpartum nurse caring for a patient 3 days postdelivery notes brown vaginal discharge. How should the nurse document this finding in the electronic health record? 1. Lochia rubra 2. Lochia serosa 3. Lochia alba 4. Brown vaginal discharge Rationales Option 1: Lochia rubra is red and bloody. Option 2: Lochia serosa is pink or brown in color. Option 3: Lochia alba is clear or whitish discharge. Option 4: Lochia is the term for discharge after birth. Question 3. A postpartum patient reports urinary frequency, urgency, and pain with urination. What is the priority nursing intervention for this patient? 1. Assess the patient’s temperature. 2. Instruct the patient to use the peri-bottle when she voids. 3. Assist the patient with a sitz bath. 4. Send a urine specimen for culture and sensitivity. Rationales Option 1: Urinary frequency, urgency, and pain with urination are possible symptoms of cystitis. The nurse should assess for fever due to the possible infection. Option 2: Using the peri-bottle will help with comfort when voiding for patients with lacerations and perineal trauma. Option 3: A sitz bath cleanses the perineum and can provide relief from pain in the genital area. Option 4: This action requires a physician’s order. Question 4. A nurse is caring for a patient 2 hours post-vaginal delivery of a term neonate. The patient suddenly complains of heavy bleeding, nausea, and dizziness. Vital signs are BP 85/49, HR 110, RR 18, O2 saturation 90%, temp 98.3 F. Based on these assessment findings, what is the priority nursing intervention? 1. Administer oxygen per nasal cannula. 2. Achieve free-flowing venous access. 3. Increase frequency of vital signs. 4. Prepare for emergency dilation and curettage. Rationales Option 1: An oxygen saturation of 90% is low and supplemental oxygen should be applied. Option 2: IV access should be achieved after oxygen is applied. Option 3: The nurse should increase the frequency of vital signs after increasing oxygenation. Option 4: An emergency dilation curettage is typically only done if the bleeding does not respond to medications and fundal massage and there are retained placental fragments. Test Taking Tip: When multiple answers are correct, remember the ABCS. In this situation, increasing oxygenation (breathing) was the priority nursing action. Question 5. A perinatal nurse is educating a patient with preeclampsia about potential complications during delivery. What important information should the nurse include in the teaching? 1. “Maternal mortality is the death of a woman from complications of pregnancy and childbirth occurring up to 2 weeks postpartum.” 2. “Maternal mortality is the death of a woman from complications of pregnancy and childbirth occurring up to 6 weeks postpartum.” 3. “Maternal mortality is the death of a woman from complications of pregnancy and childbirth occurring up to 6 months postpartum.” 4. “Maternal mortality is the death of a woman from complications of pregnancy and childbirth occurring up to 1 year postpartum.” Rationales Option 1: Maternal mortality is the death of a woman from complications of pregnancy and childbirth occurring up to 1 year postpartum. Option 2: Maternal mortality is the death of a woman from complications of pregnancy and childbirth occurring up to 1 year postpartum. Option 3: Maternal mortality is the death of a woman from complications of pregnancy and childbirth occurring up to 1 year postpartum. Option 4: Maternal mortality is the death of a woman from complications of pregnancy and childbirth occurring up to 1 year postpartum. Question 6. During routine assessment, a nurse caring for a postpartum patient notes the uterus is shifted to the side. What is the priority nursing action? 1. Notify the physician or midwife. 2. Document the findings in the electronic medical record. 3. Perform gentle fundal massage. 4. Assist the woman to the bathroom. Rationales Option 1: The physician or midwife does not need to be notified unless the position of the uterus does not return to normal after the bladder is empty. Option 2: The nurse should document the findings after assisting the patient to empty her bladder. Option 3: The fundus is most likely shifted due to a full bladder. Fundal massage should be performed for uterine atony. Option 4: The fundus is most likely shifted due to a full bladder. Fundal massage should be performed for uterine atony. Question 7. A patient on the postpartum unit reports passing an eggsized clot. What are the priority nursing interventions for this patient? Select all that apply. 1. Weigh the clot. 2. Report the findings to the physician or midwife. 3. Assist the patient to the bathroom. 4. Administer Oxytocin 10U IM. 5. Call for rapid response. Rationales Option 1: Clots the size of an egg or larger should be weighed and the findings should be reported to the physician or midwife. Option 2: Clots the size of an egg or larger should be weighed and the findings should be reported to the physician or midwife. Option 3: Assisting the patient to the bathroom is not priority at this time. Option 4: Passing a medium-sized clot does not require Oxytocin administration unless it is accompanied by heavy bleeding or uterine atony. Option 5: Passing an egg-sized clot does not necessitate a rapid response. Question 8. A nurse is caring for a patient who gave birth 30 minutes ago. Upon fundal assessment, the nurse notes moderate vaginal bleeding and a boggy uterus that does not respond to fundal massage. What is the priority nursing action? 1. Continue fundal massage. 2. Document the findings and reassess in 5 to 10 minutes. 3. Increase IV Oxytocin rate. 4. Administer misoprostol 600mg rectally. Rationales Option 1: If the uterus does not respond to fundal massage, additional nursing interventions should be implemented. Option 2: Uterine Atony is the number one cause of postpartum hemorrhage and should be treated promptly. Option 3: Universal active management of third stage of labor includes increasing the IV Oxytocin rate to assist with uterine contraction. Option 4: Misoprostol is a uterotonic and should be available in case IV Oxytocin is not effective. Question 9. What statement made by a postpartum patient indicates to the nurse understanding of weight-loss after childbirth? 1. “The average woman is almost back to her pre-pregnancy weight within 6 months.” 2. “Most women will experience significant weight loss during the first week postpartum.” 3. “I will probably lose 10 pounds as the result of delivery.” 4. “I will seat-out 2 to 3 pounds of water weight.” Rationales Option 1: At the end of 6 months, the average American woman is approximately 3 pounds above her pre-pregnancy weight. Option 2: Most women will experience significant weight loss during the first 2 to 3 weeks of postpartum. Option 3: Immediately after birth women lose approximately 11 to 12 pounds as the result of delivery and blood loss. Option 4: Diuresis results in the loss of approximately another 5 to 8 pounds post-delivery. Question 10. During a routine assessment, the nurse notes diastasis recti abdominis on a postpartum patient. What is the priority nursing intervention for this patient? 1. Continue with the assessment, as this is a normal finding. 2. Notify the physician or midwife STAT. 3. Assist the woman in applying an abdominal binder. 4. Instruct the woman to avoid using her abdominal muscles. Rationales Option 1: Separation of the rectus muscle is normal and becomes less apparent as the body returns to a pre-pregnant state. Option 2: Diastasis recti is a normal finding and does not need to be reported to the health care provider. Option 3: Women with diastasis recti do not need to wear an abdominal binder. The body will return to its pre-pregnant state over time. Option 4: Women with diastasis recti do not need to avoid using their abdominal muscles. Test Taking Tip: Do not be confused or swayed by medical terminology. In the stem of the question, “diastasis recti abdominis” is meant to distract the student. Diastasis recti abdominis is the medical term that simply means ‘separation of the rectus muscle’, which is a normal finding after childbirth. Question 11. The postpartum nurse is caring for a patient who gave birth vaginally 2 hours ago. The nurse notices continued heavy bleeding with firm fundal tone. What nursing action is a priority for this patient? 1. Assess for the presence of a vaginal hematoma 2. Perform vigorous fundal massage 3. Manually extract retained placental fragments 4. Document the findings as within normal limits Rationales Option 1: Continued heavy bleeding with firm fundal tone may indicate the presence of a genitourinary tract laceration or a hematoma of the vulva or vagina. Option 2: Fundal massage is performed for uterine atony. Option 3: The physician or midwife may manually remove retained placental fragments. Option 4: Heavy bleeding is not a normal finding. Question 12. A nurse is preparing to administer the Measles, Mumps, and Rubella (MMR) vaccine to a patient before discharge from the hospital. What question is most important for the nurse to ask prior to administering the vaccine? 1. “Do you plan on becoming pregnant again in the next 6 months?” 2. “Did you recently receive the RhoGAM?” 3. “Which arm do you prefer I give this in?” 4. “Have you ever had this vaccine before?” Rationales Option 1: Women who receive the MMR vaccine should avoid pregnancy for 4 weeks. Option 2: Rh immune globulin may interfere with the immune response to live vaccinations. Option 3: Asking which arm the patient prefers is not the priority. Option 4: Some patients will require multiple doses of MMR. Test Taking Tip: When multiple answers are similar, look for the one that is different. In this question, only one of the responses involved another medication. Question 13. A postpartum nurse is caring for a patient 48 hours post-cesarean section. The patient’s lab values are: blood type O positive, group B strep positive, rubella non-immune, hepatitis B negative. Based on these assessment findings, what order should be questioned by the nurse? 1. Measles, Mumps, and Rubella (MMR) vaccine Sub Q 2. RhoGAM 300 mcg IM 3. Hydrocodone 7.5/325 mg PO Q4hr PRN 4. Adacel 0.5 ml IM before discharge Rationales Option 1: Women who are rubella non-immune should receive the MMR after childbirth. Option 2: RhoGAM is administered to Rh-negative women who have given birth to an Rh-positive neonate. Option 3: Hydrocodone is often given for post-operative pain control. Option 4: Women should be offered the tetanus, diphtheria, and pertussis vaccine before discharge. Question 14. A nurse is caring for a postpartum patient who gave birth to her first baby 24 hours ago. What actions should the nurse perform to help promote rest and sleep? Select all that apply. 1. Administer Zolpidem 5mg PO. 2. Cluster nursing care, such as assessments and interventions. 3. Encourage woman to sleep when the baby sleeps. 4. Suggest a postpartum nanny. 5. Medicate for pain as per orders. Rationales Option 1: Zolpidem (Ambien) is a sleep medication that may be ordered by the physician as PRN. The nurse should try non-pharmacologic sleep interventions first. Option 2: Clustering nurse care will minimize disruptions to the woman’s sleep. Option 3: Women should be encouraged to sleep while the baby is sleeping, and to prioritize activities with a focus on both self-care and infant-care. Option 4: Suggesting a nanny may upset a woman and portray that the nurse thinks she is incapable of caring for her baby. Option 5: Pain interferes with sleep. Question 15. A postpartum nurse is caring for a patient immediately following vaginal delivery of a term neonate. The patient reports shortness of breath and a cough, and has the following vital signs: BP 110/73, HR 121, O2 saturation 92%, temp 99.1 F. The nurse recognizes the patient could be experiencing what complication? 1. Pulmonary embolism 2. Postpartum hemorrhage 3. Preeclampsia 4. Pulmonary edema Rationales Option 1: Women are at risk for thromboembolism, related to the increase of circulating clotting factors during pregnancy. Option 2: Signs of postpartum hemorrhage include vaginal bleeding, tachycardia, and hypotension. Option 3: Signs of preeclampsia are increased blood pressure and proteinuria. Option 4: Pregnant patients with preeclampsia are at risk for pulmonary edema and will often have crackles upon pulmonary auscultation. Question 16. Immediately after birth, the nurse notes the patient’s fundus is palpated midway between the umbilicus and symphysis pubis. What is the priority nursing action? 1. Document the findings as within normal limits 2. Perform fundal massage 3. Instruct the woman to empty her bladder 4. Reassess every 5 minutes Rationales Option 1: An expected finding immediately after birth is a uterine fundus that is palpated midway between the umbilicus and symphysis pubis and is firm and midline. Option 2: Fundal massage is performed for uterine atony. Option 3: A full bladder can cause the uterus to be shifted from the midline and/or above the umbilicus. Option 4: Fundal assessment should be performed every 15 minutes for the first hour following delivery. Question 17. A postpartum patient expresses concern that she will get a blood clot in her leg because her mother had one after her delivery. What is the most therapeutic response by the nurse? 1. “Blood clots do not run in families, so you have nothing to worry about.” 2. “I understand your concern. Let’s take a look at the back of your legs together.” 3. “Women are only at risk for developing blood clots during pregnancy.” 4. “I will assist you to ambulate around the hallway so that doesn’t happen.” Rationales Option 1: This answer dismisses the patient’s concern. Option 2: The nurse should validate the patient’s concern and teach her how to assess her calves and groin for deep vein thrombosis. Option 3: Increase coagulability associated with pregnancy continues into the post-delivery period. Option 4: This response is not the most therapeutic. Test Taking Tip: Eliminate answers that do not include therapeutic communication. Avoid dismissing a client’s concern or changing the subject. Question 18. A postpartum nurse is caring for a patient who gave birth 1 hour ago following a 24-hour long induction. The patient had an epidural for pain control during labor. What assessment finding should immediately be reported to the healthcare provider? 1. Boggy uterus 2. Bilateral lower extremity numbness 3. Uncontrollable shaking 4. Moderate vaginal bleeding Rationales Option 1: Uterine atony is the number one cause of postpartum hemorrhage and should be reported to the healthcare provider. Option 2: Epidurals commonly cause numbness in the legs. Option 3: Shaking is common immediately following delivery. Option 4: Moderate lochia rubra is a normal finding in the hour following delivery. Question 19. The postpartum nurse is preparing to ambulate a patient who received an epidural. What is the priority nursing intervention for this patient? 1. Assess for decreased nerve sensation. 2. Assess for vaginal bleeding. 3. Assess for bladder distension. 4. Assess for spinal headache. Rationales Option 1: Epidural or spinal anesthesia causes lack of sensation that may last several hours. Option 2: Vaginal bleeding is an expected finding for a woman in the immediate postpartum period. Option 3: Assessing for bladder distension is not the priority when preparing to assist a patient to ambulate for the first time after receiving an epidural. Option 4: Spinal headache does not typically present until 24 to 48 hours after delivery. Test Taking Tip: The answer choice “assess for spinal headache” is a distractor. The student might think this is the correct answer because it pertains to the stem of the question stating the client had an epidural. The correct answer is “assess for decreased nerve sensation” and is a safety issue. Question 20. Which response by a postpartum patient indicates to the nurse that learning of uterine involution has taken place? Select all that apply. 1. “My uterus will stay this big until I get my period again.” 2. “It will take between 6-8 weeks for my uterus to return to normal size.” 3. “Contractions will cause my uterus to shrink.” 4. “My uterus will not be as small as it was before I had a baby.” 5. “My uterus will return to the size of a volleyball.” Rationales Option 1: Menses does not affect uterine involution. Option 2: Involution of the uterus takes between 6-8 weeks post-delivery. Option 3: Uterine involution occurs through contractions, atrophy of the uterine muscles, and a decrease in the size of uterine cells” Option 4: The uterus will revert to pre-pregnancy size through the process of involution. Option 5: The typical size of a uterus is comparable to a pear. Test Taking Tip: Do not get hung up on medical terminology. The term “uterine involution” is meant to be a distractor. The student should identify that uterine involution just means the normal “shrinking” of the uterus. CH. 13 Question 1. A patient is in the office during the second trimester of pregnancy. The patient is concerned that her husband stated that he never fantasized about becoming a father as a child. What is the appropriate nursing response? 1. “Men often do not fantasize about fatherhood as children.” 2. “He will probably not be a good father.” 3. “He will come around eventually.” 4. “That is very unusual, and counseling might be helpful.” Rationales Option 1: Men are different than women and generally do not fantasize about fatherhood as children, nor do they usually role-play while they are children. Option 2: This statement is inaccurate and is not beneficial to the patient’s concern. Option 3: While this is likely true, this statement does not address the patient’s concern. Option 4: The statement made by the husband is common for men, so this response is not accurate. Question 2. A patient on the postpartum unit mentions a concern to the nurse about the baby bonding between the infant and father. The nurse discusses the relationships formed between parents and infants. Which component does the nurse discuss as bidirectional? 1. Love 2. Admiration 3. Bonding 4. Attachment Rationales Option 1: While love may be an emotion that is felt, it is not used to describe a relationship component. Option 2: Admiration may be an emotion that new parents feel towards the infant, but is not bidirectional. Option 3: Bonding is unidirectional and involves the parent bonding with the infant. Option 4: Attachment is bidirectional and involves the attachment formed by the parent with the infant and by the infant with the parent. Question 3. A nurse is completing hospital orientation on the postpartum unit at a large hospital. During the orientation, the nurse participates in some classroom education on nursing theory. Which theorist would be included when discussing the early foundations of postpartum care? 1. Reba Rubin 2. Hildegard Peplau 3. Ramona Mercer 4. Jean Watson Rationales Option 1: Reba Rubin formulated her theory surrounding the process of postpartum adaptation in 1984. Option 2: Hildegard Peplau is known for her theory work in the specialty area of mental health. Option 3: Ramona Mercer was a student and colleague of Rubin’s and completed theoretical work on the maternal role attainment in 1995. Option 4: Jean Watson is best known for her caring theories in nursing. Question 4. The nurse walks into a postpartum room noting a screaming infant in a crib near the bedside. Both parents are asleep. Which statement by the mother shows the need for further assessment for ineffective bonding? 1. “Sorry, it won’t stop crying, and we are so tired.” 2. “We are so tired, she kept us up all night.” 3. “We are so tired, we must have been sound asleep.” 4. “We are so tired. What if this happens at home?” Rationales Option 1: Referring to the child as “it” can reflect bonding issues. Option 2: This response acknowledges the infant’s gender and shows the parents were caring for their baby all night. Option 3: This response does not show the mother having ineffective bonding because it doesn’t mention the baby. Option 4: This response is normal to the new parent to worry a little. Question 5. The nurse enters the room of a postpartum patient and partner to find the patient sitting in the chair holding the infant in a cradle hold position. The partner states the mother is crying and states that she wants to hold the baby but is very uncomfortable. What position would the nurse help the patient into for more comfort? 1. Cross cradle hold in chair 2. Side-lying position in bed with infant 3. Place infant in bassinet 4. In the bed in a cradle position Rationales Option 1: The cross cradle position would cause similar discomfort to the mother. Option 2: The side-lying position is okay to utilize as long as the mother does not fall asleep with the infant. Since there is family in the room, this position would be okay. Option 3: Placing the infant in the bassinet does not allow the mother to hold the infant as desired. Option 4: A cradle position in the bed would cause the same discomfort for the patient. Question 6. The nurse is performing follow up phone calls to postpartum mothers. She calls a woman who is 4-days postpartum and the woman says, “I don’t know what’s wrong. I keep crying for no reason.” The nurse recognizes the statement as what nursing diagnosis? 1. Lack of taking-hold 2. Attachment/bonding issues 3. Postpartum depression 4. Postpartum blues Rationales Option 1: Lack of taking hold does not accompany crying for no reason. Option 2: Attachment and bonding issues are not present by the woman’s response. Option 3: The woman has no other signs or symptoms to be diagnosed with postpartum depression Option 4: Crying for no reason is a sign of postpartum blues. Question 7. The postpartum nurse is reviewing the chart of a lesbian couple. When answering the patient’s questions, which would prompt the nurse to provide further education? 1. “We both plan to breastfeed, but can we start with a bottle?” 2. “We both plan to breastfeed, can the baby latch onto my breast within the first hour?” 3. “We both plan to breastfeed therefore we should both do skin to skin contact.” 4. “We both plan to breastfeed, but we will need a lactation consultant to help with options.” Rationales Option 1: This response shows the mothers does not understand the initiation of lactation starts with skin to skin contact and breastfeeding within one hour of birth. Option 2: This response shows the mother understands how important it is to start breastfeeding early on. Option 3: Skin to skin contact has been shown to aid in better breastfeeding. Option 4: This response shows that they will need professional help with the initiation of lactation in both mothers. Question 8. During a prenatal visit with a lesbian couple, the couple expresses a desire to both breastfeed the infant following delivery. What is the best response by the nurse? 1. “It is only possible for the pregnant patient to breastfeed.” 2. “I will let the provider know to discuss methods for inducing lactation.” 3. “The infant will experience nipple confusion if both of you try to breastfeed.” 4. “You should consider waiting to breastfeed when you carry the next infant yourself.” Rationales Option 1: This is not a true statement, as breastfeeding can be induced. Option 2: Acknowledging the patient request and passing the request to the provider is an appropriate response. Option 3: While this is a possibility, it undermines the patient request so is not a great response. Option 4: This is an option, however this response does not acknowledge the patient request. Question 9. The nurse educator for the Neonatal Intensive Care Unit (NICU) is preparing a pamphlet for parents when the newborn is admitted to the NICU after delivery. Attachment is a common area of concern that new parents have in these situations. What suggestions can the nurse include in the pamphlet on enhancing attachment? Select all that apply. 1. Take pictures of the infant for the mother 2. Take a wheelchair to visit the infant when possible 3. Include the times that the parents can call the NICU 4. Offer suggestions for visiting times for the NICU 5. Provide a breast pump so the new mother Rationales Option 1: Pictures for the mother can enhance the relationship and attachment the parent feels towards the newborn when there is distance due to a NICU stay. Option 2: Visiting the infant as much as possible once able enhances the relationship, bonding and attachment. Option 3: Limiting the times that parents can call or visit the NICU limits the attachment with the infant. Option 4: Limiting the times that parents can call or visit the NICU limits the attachment with the infant. Option 5: Allowing the mother to pump breastmilk offers a connection to parent the infant that is in the NICU and can enhance the feelings of attachment. Question 10. The nurse is caring for a patient on the postpartum unit. The patient is confined to a wheelchair and the nurse is preparing discharge instructions. What should the nurse consider for this patient? Select all that apply. 1. Call child protective services for follow-up on the infant. 2. Discuss the needs for the home setting to successfully care for the infant. 3. Review standard discharge instructions for new parents. 4. Consider referral to social services for further assistance and resources. 5. Ask if there are able-bodied family members who will be caring for the baby. Rationales Option 1: There is no indication that child services need to be involved in this case. Option 2: Discussing the needs that may be necessary in the home setting is appropriate for discharge. Option 3: All standard instructions should be reviewed, including infant care and postpartum recovery. Option 4: If additional requirements are needed in the home setting, social work can be of assistance. Option 5: This is not an appropriate consideration, as there is no reason to assume the patient cannot care for the infant. Question 11. A nurse assigned to care for a couple on the postpartum unit approaches the charge nurse with a concern. The nurse is unsure if the parents are forming an attachment with the infant due to lack of eye contact. How should the charge nurse respond to the concern? 1. Ask the nurse if there are any other positive indications for bonding. 2. Tell the nurse to ask the patients if they are happy to have a baby. 3. Consider the use of a translator to clarify information. 4. Assign a new nurse to care for the couple and infant. Rationales Option 1: Eye contact with the infant is just one observation of positive bonding, but is also considered inappropriate in some cultures. It is best to look at all behaviors before drawing a conclusion. Option 2: While this is a possibility, the charge nurse does not stimulate critical reflection in the nurse with this answer. Option 3: This may be a possibility, however, this assumes that lack of eye contact is a problem. Option 4: There is no indication that assigning a new nurse to the family is required at this time. Question 12. The nurse is assessing a new mother who brought her 6-month-old infant for a well check. The mother is 16-years-old and her mother came with her to the visit. The infant’s grandmother is holding the new baby and answering all of the questions. What part of the becoming a mother process does the nurse note to be lacking? 1. Commitment, attachment and preparation 2. Acquaintance and learning to care 3. Learning a new normal 4. Achieving maternal identity Rationales Option 1: Commitment, attachment and preparation is seen by the mother coming to the appointment with her mother. Option 2: Acquaintance and leaning to care is not seen in this background of the question. Option 3: Indeed, the new mother must learn a new role, but the identity of the mother is what the nurse sees lacking. Option 4: Achievement of a maternal identity begins around 4 months. Question 13. The nurse is caring for a patient that speaks Spanish. When using an interpreter, it's inappropriate to use which phrase when talking to the patient? 1. \"Tell her it\"s okay and I will be here with her.\" 2. \"You\"re 5cm dilated, which means you are halfway to having to push.\" 3. \"You baby needs to eat, how can I help you feed her?\" 4. \"Did you baby have a wet diaper or a dirty diaper?\" Rationales Option 1: When using an interpreter, avoid saying, “Tell him/her....” Option 2: “You\"re 5cm dilated, which means you are halfway to having to push." This statement gives the patient information and clarification of the information. Option 3: "Your baby needs to eat, how can I help you feed her?" This statement offers help and doesn’t expect the patient to do anything by herself. Option 4: \"Did you baby have a wet diaper or a dirty diaper?\" This statement is closed ended with choices. Instead of Yes or No questions. Question 14. The parents of a newborn are ecstatic that the infant is easy to interact with the day after delivery. The nurse takes this opportunity to discuss infant alert states. What knowledge related to infant states will the nurse base the appropriate response on? 1. Deep sleep 2. Quiet alert 3. Drowsy 4. Active alert Rationales Option 1: During deep sleep, the infant will be less responsive to stimuli. It is best to not wake the infant during this stage. Option 2: Quiet alert is the best state for infant interaction. Option 3: During a drowsy state, the infant will respond to gentle stimuli. Option 4: During active alert, the infant requires comforting and a decrease in stimuli. Question 15. When planning care for the following patients, the postpartum nurse anticipates some delayed bonding with three of the assigned couplets. Which couple does the nurse anticipate having little to no concerns with newborn bonding? 1. Infant born at 28 weeks gestation 2. Labor lasting 8 hours 3. Gestational diabetes during the pregnancy 4. Patient recently separated from spouse Rationales Option 1: Premature infants that are separated from the mother can lead to delayed bonding concerns. Option 2: Long or difficult labors can contribute to bonding delays, this labor length is average and does not indicate a concern. Option 3: Pregnancy complications can contribute to delayed bonding following delivery. Option 4: Lack of social support systems can impact bonding with the infant. Test Taking Tip: For this question, the focus must be on what is normal. Be sure to consider the risks associated with each answer option, and determine which answer has the least risk. Question 16. The father of a 5-week-old newborn calls the labor and delivery department. He mentions his wife is constantly crying and won’t sleep. What are appropriate nursing interventions based on this information? Select all that apply. 1. Explain signs and symptoms of postpartum depression 2. Provide resources 3. Let it go for another week or so 4. Ask what he has done at home so far 5. Ask to speak to her and refer to physician Rationales Option 1: This is important for the father to know to understand why she may be feeling this way. Option 2: This is important for the father to be able to contact the right people to help. Option 3: Letting it go can turn into psychosis and suicidal thoughts. Option 4: This can help gather what he has done to try to help and encourages him that calling is the best help he could do. Option 5: It’s important to triage the patient over the phone to make sure she is safe. Question 17. A nurse in the provider office is assessing a patient who is deaf and uses sign language for communication. The patient is married to a partner who is also deaf. The couple expresses interest in attempting pregnancy. How does the nurse best respond to the couple? 1. “That is a terrible idea, you are both hard of hearing.” 2. “Are there adaptations that would help you with an infant?” 3. “How would you know the baby was crying?” 4. “The provider will talk to you about ways to prevent pregnancy.” Rationales Option 1: This is a judgmental statement, and should not even be considered by the nurse. Option 2: Most parents with sensory impairments have considered the need for adaptations in caring for a newborn. Curiosity is okay to demonstrate when rapport is established. Option 3: While this appears to address the need for adaptations, it is worded in a confrontational manner. Option 4: This indicates that the couple should not attempt pregnancy. Question 18. During discharge education, the nurse notes the postpartum patient starting to fall asleep. What is the appropriate nursing response to the patient? 1. “You will need to stay awake to learn this important information.” 2. “You should rest while the baby is asleep, and I will come back later to review this information.” 3. “You will not be able to go home until tomorrow, since you are having trouble staying awake still.” 4. “You can nap and I will just review this information with your partner.” Rationales Option 1: While the information is important, this response is not therapeutic and does not acknowledge the fatigue experienced by new parents. Option 2: Learning occurs best when the new parents are well rested. A good time to rest is when the infant is resting. The nurse should return when the patient is well rested to allow for an effective educational session. Option 3: Fatigue is a common occurrence in new parents and does not impact discharge timing. Option 4: Discharge education should be provided to both the patient and partner, so this is not the best option. Test Taking Tip: Always consider therapeutic communication with the client, and never sound condescending of scolding. Question 19. The nurse assesses a mother's bonding with her new baby. Which action made by the mother does the nurse identify as the initial maternal phase? 1. The mother relives and speaks of the birthing experience 2. The mother responding and picking up the infant when she cries 3. The mother goes back to work. 4. The mother asking questions about infant care Rationales Option 1: The mother reliving and speaking of the birthing experience represents the initial "taking in" maternal phase. Option 2: The mother responding and picking up the infant when she cries is a cue later during the second stage when the mother starts caring for the infant on her own. Option 3: The mother going back to work or school is part of the later "letting-go" maternal phase. Option 4: The mother asking questions about infant care comes later during the second stage when the mother is caring for her newborn. Question 20. A new nurse is assigned to care for a lesbian couple on the mother-baby unit. The nurse is heterosexual has never cared for a homosexual patient before. What is important for the nurse to do prior to meeting the couple? 1. Perform self-reflection of personal beliefs on homosexuality. 2. Review the laws for same-sex parents. 3. Ask the previous nurse if both parents are called mom. 4. Discuss the care with the charge nurse for the shift. Rationales Option 1: When caring for patients who may be different from oneself, it is imperative to reflect on one’s personal beliefs and consider the impact that beliefs have on behavior. Option 2: While it may be important to understand the laws that pertain to this couple, it would not be the most time sensitive consideration. Option 3: This information would not impact the care of the patient in a significant manner. Option 4: While planning care and consulting with the charge nurse can be important, it is not the most time sensitive item for the patient.