A woman, who wishes to breastfeed, advises the nurse that she has had breast augmentation surgery. Which of the following responses by the nurse is appropriate?

Correct Answer: D

Rationale: The correct response is D) Women who have implants are often able exclusively to breastfeed. This is the appropriate response because having breast implants does not necessarily prevent a woman from being able to breastfeed. Breast augmentation surgery typically does not affect the milk ducts or the ability to produce milk. It is important for the nurse to provide accurate and supportive information to encourage the woman's desire to breastfeed. Option A is incorrect because breast implants do not inherently contaminate breast milk with toxins. Option B is incorrect as breast augmentation surgery does not necessarily indicate a deficiency in glandular tissue. Option C is incorrect because while some women may experience difficulty with latching initially, it is not a general rule for all women with breast implants. Educational context: It is crucial for nurses to have accurate knowledge about breastfeeding and breast augmentation to provide appropriate support and guidance to women who wish to breastfeed after surgery. Understanding the facts and dispelling myths surrounding breastfeeding with implants can help empower women to make informed decisions about their breastfeeding journey.

Correct Answer: A

Rationale: In this scenario, the correct answer is option A) Urine output of 200 mL for the last 8 hours. This finding is critical to report to the obstetrician because a decreased urine output postpartum could indicate inadequate renal perfusion, potentially due to continued hemorrhage or other complications. This information is crucial for the obstetrician to assess the client's fluid status and intervene promptly if necessary. Option B) Weight decrease of 2 pounds since delivery may not be as urgent to report immediately as changes in urine output. While weight loss is expected postpartum, a significant decrease could indicate excessive blood loss or fluid shifts, but it is not as time-sensitive as monitoring urine output in this context. Option C) Drop in hematocrit of 2% since admission is important but may not be as indicative of the current status as urine output in the immediate postpartum period. Hematocrit changes take time to manifest and may not reflect acute changes as rapidly as urine output. Option D) Pulse rate of 68 beats per minute, while within the normal range, is not as concerning as changes in urine output in this context. Pulse rate alone may not provide enough information to assess the client's overall condition post hemorrhage without considering other parameters like blood pressure and clinical symptoms. In an educational context, it is essential for nurses caring for postpartum clients to understand the significance of monitoring urine output as a vital sign, especially in cases of postpartum hemorrhage. Nurses need to recognize the importance of timely communication of critical findings to the healthcare team to ensure prompt interventions and optimal patient outcomes.

Correct Answer: A

Rationale: In the context of perinatal loss nursing care, understanding postpartum psychosis is crucial for providing effective care. The correct answer is A) Hallucinations. Postpartum psychosis is a severe mental health condition that can occur in the postpartum period. Hallucinations, along with delusions, are common symptoms of postpartum psychosis. These hallucinations can be auditory, visual, or tactile in nature and are often distressing for the woman experiencing them. Option B) Polyphagia refers to excessive hunger, which is not typically a symptom of postpartum psychosis. Option C) Induced vomiting is more indicative of an eating disorder like bulimia and is not a common symptom of postpartum psychosis. Option D) Weepy sadness is more characteristic of postpartum depression rather than postpartum psychosis. Educationally, understanding the differences between postpartum psychosis, postpartum depression, and other postpartum mental health conditions is essential for nurses caring for women during this vulnerable period. Recognizing the signs and symptoms of postpartum psychosis is crucial for early intervention and support for the woman and her family. By knowing the specific manifestations of postpartum psychosis, nurses can provide appropriate care and referrals to mental health professionals for further evaluation and treatment.

Correct Answer: B

Rationale: In this scenario, option B is the most appropriate action for the nurse to take. The correct answer is to carefully check the record to ensure that the RhoGAM injection was administered. This is important because the mother is Rh-negative, and if the injection was not given, there could be a risk of Rh incompatibility issues in future pregnancies. By verifying the administration of RhoGAM, the nurse can ensure the mother's safety. Option A is incorrect because the client needs the RhoGAM injection regardless of the baby's Coombs' test results. Option C is incorrect as the negative Coombs' test does not negate the need for RhoGAM in an Rh-negative mother. Option D is incorrect because RhoGAM should be given within 72 hours of delivery, not necessarily before discharge. Educationally, this question highlights the importance of understanding Rh incompatibility and the necessity of RhoGAM in Rh-negative mothers to prevent hemolytic disease of the newborn in future pregnancies. It emphasizes the critical role nurses play in ensuring proper administration of medications to prevent complications.