A nurse is assessing a client who is 8 hr postpartum and multiparous. Which of the following findings should alert the nurse to the client's need to urinate?

Correct Answer: B

Rationale: A fundus three fingerbreadths above the umbilicus indicates that the uterus is not adequately contracting, which can obstruct the flow of urine from the bladder. Postpartum clients often experience urinary retention due to decreased sensation in the bladder, trauma from delivery, and decreased bladder tone. Failure to empty the bladder promptly can lead to urinary retention and potential complications such as urinary tract infections or bladder distention. Therefore, the nurse should be alert to the client's need to urinate when assessing the fundal height.

Correct Answer: B

Rationale: The best indication that correct attachment to the breast has occurred is when the baby's mouth covers most of the areolar surface. This is important because proper latch and attachment are crucial for effective breastfeeding. When the baby's mouth covers most of the areola, it ensures that the baby is latched onto the breast properly, allowing them to feed efficiently and receive an adequate amount of milk. This also helps prevent nipple soreness and pain for the mother. Additionally, when the baby's mouth covers most of the areola, it helps ensure that the baby is positioned correctly to effectively stimulate milk production and flow.

Correct Answer: B

Rationale: In the scenario of a newborn with a low Apgar score of 4 at 1 minute, the priority nursing intervention is Option B: Administer oxygen and stimulate the baby. This is the correct choice because a low Apgar score indicates the need for immediate interventions to support the newborn's transition to extrauterine life. Administering oxygen helps improve oxygenation, vital for organ function, while stimulation can help initiate breathing efforts. Option A (Placing the baby in skin-to-skin contact with the mother) is a beneficial intervention for bonding and thermoregulation but not the priority in this acute situation requiring immediate medical attention. Option C (Delay interventions and reassess in 5 minutes) is unsafe as a low Apgar score necessitates prompt action to prevent further deterioration. Option D (Begin chest compressions immediately) is not indicated unless the newborn is in cardiac arrest, which is not the case here based on the Apgar score. In an educational context, understanding the significance of Apgar scores and the appropriate responses to low scores is crucial for nurses caring for newborns. Quick and accurate assessment followed by timely interventions can significantly impact the outcomes for newborns in distress. Nurses must be prepared to act swiftly and effectively in such critical situations to ensure the best possible care for neonates.

Correct Answer: A

Rationale: The correct answer is not A) Provide formula supplements; it is actually B) Demonstrate proper latching techniques. Supporting breastfeeding for a first-time mother is a crucial aspect of maternal and newborn nursing care. Demonstrating proper latching techniques is essential for successful breastfeeding as it helps ensure the baby receives an adequate milk supply, promotes bonding between mother and baby, and prevents issues like sore nipples or inadequate milk transfer. Option A) Providing formula supplements is not the best course of action as it can interfere with establishing a good milk supply and may lead to nipple confusion for the baby. Option C) Recommending stopping breastfeeding is also incorrect as breastfeeding offers numerous benefits for both mother and baby and should be encouraged and supported whenever possible. Option D) Providing pacifiers to prevent overfeeding is not relevant to the question and may actually hinder breastfeeding success by reducing the baby's time at the breast. In an educational context, it is important for nurses to understand the significant role they play in supporting and promoting successful breastfeeding practices. By providing education, guidance, and support to first-time mothers, nurses can help enhance maternal and infant health outcomes, strengthen the mother-infant bond, and contribute to overall family well-being. It is crucial for nurses to stay updated on evidence-based practices in breastfeeding support to provide the best care possible to mothers and newborns.

Correct Answer: A

Rationale: In the scenario of a mother experiencing excessive bleeding two hours postpartum, the first action should be to monitor her blood pressure and heart rate, which are vital signs that can provide immediate information about her condition. By monitoring these parameters, healthcare providers can quickly assess the severity of the bleeding and the mother's hemodynamic status. This information is critical for determining the appropriate course of action. Performing uterine massage to stimulate contractions (option B) is an important intervention to help control postpartum bleeding caused by uterine atony. However, before initiating this intervention, it is essential to assess the mother's vital signs to ensure that she is stable enough to undergo the procedure. Preparing for a possible blood transfusion (option C) is premature without first evaluating the mother's current status through vital sign monitoring. Blood transfusion may be necessary in cases of severe postpartum hemorrhage, but it should be based on a comprehensive assessment of the mother's condition. Notifying the healthcare provider immediately (option D) is important, but it should not precede the initial assessment of vital signs. Prompt notification should follow the assessment to ensure timely involvement of the healthcare team in managing the situation effectively. In an educational context, understanding the prioritization of interventions in postpartum hemorrhage is crucial for maternal and newborn nurses. By prioritizing actions based on assessment findings, nurses can provide timely and appropriate care to prevent further complications and ensure the well-being of the mother and newborn. Monitoring vital signs as the first action aligns with the principles of assessing and managing postpartum hemorrhage effectively.