A client, G1 P0000, is PP1 from a normal spontaneous delivery of a baby boy, Apgar 5/6. Because the client exhibited addictive behaviors, a toxicology assessment was performed; the results were positive for alcohol and cocaine. Which of the following interventions is appropriate for the nurse to perform for this postpartum client?

Correct Answer: D

Rationale: The correct intervention for the nurse to perform for this postpartum client is option D: Provide the client with supervised instruction on baby-care skills. Rationale: 1. Correct Answer (D): Providing supervised instruction on baby-care skills is crucial in this situation because the client has exhibited addictive behaviors, which can impair her ability to care for her newborn. By offering guidance and supervision, the nurse can ensure the safety and well-being of the baby while supporting the client in developing essential parenting skills. 2. Incorrect Answers: - Option A (Strongly advise the client to breastfeed her baby): Breastfeeding while under the influence of alcohol and cocaine can pose serious risks to the baby's health. It is not safe to encourage breastfeeding in this scenario. - Option B (Perform hourly incentive spirometer respiratory assessments): This intervention is not relevant to the client's current situation of substance use and the need for baby-care education. - Option C (Suggest that the nursery nurse feed the baby in the nursery): Separating the baby from the mother can disrupt bonding and breastfeeding, which are essential for the infant's well-being. It is important to support mother-infant bonding whenever possible. Educational Context: In postpartum care, nurses play a vital role in supporting new mothers, especially those facing challenges such as substance abuse. Providing education and guidance on baby-care skills is crucial to ensure the safety and optimal development of the newborn. By offering supervised instruction, nurses can empower mothers to overcome obstacles and become confident caregivers for their infants. It is essential for healthcare professionals to approach these sensitive situations with empathy, non-judgmental attitude, and a focus on promoting the best outcomes for both the mother and the baby.

Correct Answer: A

Rationale: In the postpartum period, monitoring a client after a significant hemorrhage is crucial to detect any signs of complications early. In this scenario, the nurse should report the urine output of 200 mL for the past 8 hours to the obstetrician. This finding indicates inadequate renal perfusion, potentially due to hypovolemia from the hemorrhage. Low urine output can be a sign of acute kidney injury, which can worsen if not addressed promptly. The weight decrease of 2 pounds since delivery (option B) is a common postpartum finding attributed to the loss of the baby, placenta, and amniotic fluid. It is not a cause for concern unless it is rapid and accompanied by other symptoms. A drop in hematocrit of 2% since admission (option C) is expected due to intravenous fluid administration during delivery, and a pulse rate of 68 beats per minute (option D) is within the normal range for a postpartum client. Educationally, understanding the significance of urine output in the postpartum period after a hemorrhage reinforces the importance of assessing for signs of hypovolemia and organ perfusion. This knowledge equips nurses to provide comprehensive care and advocate for timely interventions to prevent complications in postpartum clients.

Correct Answer: C

Rationale: The correct answer is C) Fundus firm at umbilicus. Postpartum hemorrhage is a significant concern after childbirth, especially in grand multiparas. Methergine is a medication commonly used to prevent or treat postpartum hemorrhage by promoting uterine contraction, which helps to control bleeding. A firm fundus at the umbilicus indicates that the medication is effective as it signifies proper uterine contraction, which is essential for preventing excessive bleeding. Option A, blood pressure 120/80, and option B, pulse rate 80 bpm and regular, are not direct indicators of the effectiveness of Methergine in preventing postpartum hemorrhage. While changes in blood pressure and pulse rate can occur as side effects of the medication, they do not directly confirm its effectiveness in controlling bleeding. Option D, an increase in prothrombin time, is incorrect because Methergine does not affect clotting factors or coagulation parameters like prothrombin time. Monitoring clotting factors would be more relevant if the patient was on anticoagulant therapy. This question is important in the context of postpartum care as it highlights the need for nurses to understand the actions of medications commonly used in the management of postpartum complications, such as hemorrhage. Recognizing the appropriate assessment findings that indicate the effectiveness of medications like Methergine is crucial for providing safe and effective care to postpartum patients.

Correct Answer: A

Rationale: In the context of postpartum psychosis, the correct answer is A) Hallucinations. Postpartum psychosis is a severe mental health condition that can occur in some women following childbirth. Hallucinations, which involve perceiving things that are not actually present, are a common symptom of postpartum psychosis. These hallucinations can be auditory, visual, or tactile in nature and can significantly impact the woman's perception of reality. The incorrect options are B) Polyphagia, C) Induced vomiting, and D) Weepy sadness. Polyphagia refers to excessive hunger, which is not typically associated with postpartum psychosis. Induced vomiting is not a characteristic symptom of postpartum psychosis and is more commonly seen in eating disorders. Weepy sadness, while a common symptom of postpartum depression, is not specific to postpartum psychosis, which involves more severe symptoms like hallucinations and delusions. Educationally, it is crucial for healthcare providers and caregivers to recognize the signs and symptoms of postpartum psychosis to ensure early intervention and appropriate treatment. Understanding the distinguishing features of postpartum psychosis, such as hallucinations, can help in prompt identification and referral for specialized mental health support for the affected woman. This knowledge is essential for providing comprehensive care and support to women experiencing postpartum mental health challenges.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) The baby swallows after every 5th suck. This observation indicates successful intervention because it demonstrates effective milk transfer and feeding by the infant. When a baby swallows, it signifies that they are extracting milk from the breast successfully. Option A) The mother's nipples being soft to the touch is not a reliable indicator of successful breastfeeding as it does not directly relate to the baby's feeding ability. Option C) The baby's pre- and postfeed weight change of 20 milliliters might indicate successful feeding, but it is not as immediate or direct an observation as the baby swallowing during feeds. Option D) The mother squeezing her nipples during manual expression is unrelated to the baby's feeding ability and does not provide insight into the infant's feeding success. In an educational context, it is crucial for healthcare providers to understand the signs of effective breastfeeding to support mothers and babies in establishing successful breastfeeding relationships. Observing infant feeding cues, such as swallowing, is essential for assessing breastfeeding effectiveness and ensuring adequate milk transfer for the baby's nourishment and growth.