Question 1

Which of the following safety devices is most appropriate for the nurse making home visits?

Accepted Answer

A cell phone is the most appropriate safety device for a nurse making home visits. It allows the nurse to call for help if needed, and to stay in communication with their supervisor or team members. Maps of the area may be helpful for navigation, but are not safety devices. Personal handguns and cans of mace are not appropriate for healthcare professionals as they can create a dangerous situation and may not be legal in all areas.

Question 2

The nurse is caring for a patient who delivered by cesarean birth. The patient received a general anesthetic. The nurse would encourage which of the following in order to prevent or minimize abdominal distention?

Accepted Answer

B,C,D

Question 3

The postpartum patient delivered 4 hours ago. She has a mediolateral episiotomy and large hemorrhoids. She is rating her pain at 7 on a scale of 1-10. She has a history of anaphylactic reaction to Tylenol (acetaminophen). Which nursing action would be best?

Accepted Answer

Ibuprofen is a suitable alternative for pain relief in this case, as the patient has a history of anaphylactic reaction to acetaminophen, which is present in Percocet.

Question 4

The nurse is caring for a patient who plans to relinquish her baby for adoption. The nurse would implement which of the following approaches to care?

Accepted Answer

When caring for a patient who plans to relinquish her baby for adoption, the nurse should encourage the patient to express her emotions, respect any special requests for the birth, acknowledge the grieving process in the patient, and allow for access to the infant if the patient requests it. However, it may not always be appropriate to encourage the patient to see and hold her infant, as this could be too emotionally distressing for some patients. Therefore, option A is not the best choice.

Question 5

The hospital is developing a new maternity unit. What aspects should be included in the planning of this new unit to best promote family wellness?

Accepted Answer

Providing couplet care, which involves pairing a mother and her newborn with the same nurse or group of nurses, promotes family bonding and allows for individualized care. The other options, while potentially helpful, do not have as strong a focus on family wellness.

Question 6

The nurse is caring for a patient who had a cesarean birth 4 hours ago. Which of the following interventions would the nurse implement at this time?

Accepted Answer

These interventions are all important for the patient's recovery after a cesarean birth. Analgesics will help to relieve pain, ambulation will help to prevent blood clots, leg exercises will help to improve circulation, and coughing and deep-breathing will help to prevent pneumonia. Breathing, relaxation, and distraction techniques can help to reduce anxiety and promote comfort.

Question 7

The nurse is preparing to receive a newly delivered patient. The patient is a young single mother who is relinquishing custody of her newborn through an open adoption. What action is most important?

Accepted Answer

It is important to ask the patient if she wants to feed her baby and if she wants any contact with the newborn, as it is crucial to respect the mother's wishes and emotional needs during this challenging time. The nurse should be supportive and non-judgmental, and provide appropriate education and resources to help the patient cope with her decision. Assigning a room on the GYN surgical floor or discussing the mother's health instead of the baby's well-being may not be as relevant or helpful in this situation. Discharging the patient at 24 hours postdelivery may also not be appropriate, depending on the circumstances and care plan.

Question 8

On the second day postpartum, the patient experiences engorgement. To relieve her discomfort, the nurse should encourage the patient to:

Accepted Answer

Applying ice packs to the breasts can help reduce swelling and relieve discomfort associated with engorgement.

Question 9

The nurse instructs the postpartum client that she can resume light housekeeping after the:

Accepted Answer

The client can resume light housekeeping after the second week at home. It is important to allow the client time to rest and recover during the first week at home, and the six-week postpartum checkup is typically when healthcare providers will assess the client's healing progress and provide recommendations for resuming normal activities.

Question 10

The nurse is caring for a 15-year-old patient that gave birth to her first child yesterday. What action is the best indicator that the nurse understands the parenting adolescent?

Accepted Answer

The nurse should focus on helping the adolescent mother understand her baby's needs and behaviors, which is crucial for developing her parenting skills.

Question 11

The patient having her second child is scheduled for a cesarean birth because the baby is in a breech presentation. The patient states, "I'm wondering what will be different this time compared with my first birth, which was vaginal." What response is best?

Accepted Answer

Option B is correct because wearing compression stockings is a common practice after cesarean sections to prevent deep vein thrombosis (DVT), which is a risk due to decreased mobility after surgery. This response directly addresses a specific difference the patient can expect with a cesarean birth compared to a vaginal birth. Options A, C, and D do not provide specific or accurate information about the differences related to the mode of delivery.

Question 12

The community health nurse is presenting a seminar to new mothers about breastfeeding. When discussing weaning, which new mother's statement suggests a need for further teaching?

Accepted Answer

The statement "Slow weaning should take place over a period of several months" suggests a need for further teaching because the recommended duration for weaning varies depending on the baby's readiness and the mother's desire. It is important to individualize the weaning process, and it may not always take several months. The nurse should clarify the appropriate length of time for weaning based on the needs of the baby and mother.

Question 13

The nurse had completed a postpartum assessment on a patient who gave birth to her first child 12 hours ago. She is nauseated, but has not vomited in the last 2 hours. Her fundus was boggy, and firmed with massage to 1 FB ↓ U, moderately heavy lochia rubra, perineum ecchymotic and edematous, and pain rating 6 on scale of 1-10. Her partner is present and supportive. Breastfeeding has been successful three times. Which nursing diagnosis has the highest priority for this patient?

Accepted Answer

The patient's evidence of moderate uterine bleeding, combined with nausea, puts her at risk for deficient fluid volume. This is the highest priority nursing diagnosis as it could potentially lead to complications such as hypovolemic shock. The other options, while still important, are not as urgent. Acute pain related to perineal trauma would be addressed, but does not carry the same risk as fluid volume deficits. Readiness for enhanced family coping can be addressed after the patient's physical needs are stabilized, and knowledge deficit related to newborn care can be addressed at a later time as well.

Question 14

During a home care visit, the new mother complains of breast engorgement. Which intervention is most appropriate for recommendation by the home care nurse?

Accepted Answer

A well-fitted nursing bra provides support and helps to prevent engorgement.

Question 15

The maternal home care nurse is orienting a new nurse. During orientation, they are discussing maternal psychological adaptations and stressors. Which statement by the maternal home care nurse reflects the correct approach to addressing potential and actual postpartum depression in maternal patients?

Accepted Answer

Teaching about postpartum depression is a routine part of education for all maternal patients. It is important to provide education on postpartum depression to all maternal patients as it is a common concern that can impact their health and the health of their baby. By making it a routine part of education, patients are more likely to feel comfortable discussing their concerns and seeking help if needed.

Question 16

During a home care visit, a couple expresses a desire for cosleeping, or sleeping in the same bed with their newborn baby. Which nursing response is most appropriate?

Accepted Answer

The correct response is C because cosleeping has been identified as a risk factor for sudden infant death syndrome (SIDS) by the American Academy of Pediatrics. The nurse should provide education on specific safety guidelines to minimize this risk if the family still wishes to cosleep. The other options are incorrect and potentially harmful. A suggests that there are no physical risks, which is inaccurate. B suggests placing the baby on their stomach to sleep, which is unsafe and increases the risk of SIDS. D suggests using a comforter, which also increases the risk of suffocation.

Question 17

A new parent is concerned about spoiling her newborn. The home care nurse teaches the mother that:

Accepted Answer

Meeting the infant's needs develops a trusting relationship. Infants cannot manipulate their caregivers, and crying is a form of communication that should be responded to promptly. Neglecting an infant's needs can result in developmental and emotional problems. Therefore, it is important to attend to their needs promptly and consistently to develop a trusting relationship.

Quiz 30: The Postpartum Family: Early Care Needs and Home Care