Immediately after delivery, a woman is shaking uncontrollably. Which of the following nursing actions is most appropriate?

Correct Answer: A

Rationale: In this scenario, the most appropriate nursing action is to provide the woman with warm blankets (Option A). The woman's uncontrollable shaking is likely due to postpartum shivering, which is a common physiological response to the body's readjustment after delivery. Providing warm blankets helps to increase the woman's comfort and can help alleviate the shivering. Option B, putting the woman in the Trendelenburg position, is not appropriate in this situation as it involves positioning the patient with the head lower than the rest of the body, which is not indicated for postpartum shivering. Option C, notifying the primary health care provider, is not necessary at this point as postpartum shivering is a normal occurrence and does not typically require immediate medical intervention. Option D, increasing the intravenous infusion, is also not indicated as the woman's shaking is not likely related to dehydration or inadequate fluid intake. Educationally, it is important for healthcare providers to understand the common physiological changes that occur postpartum and how to appropriately address them to ensure the well-being and comfort of the mother. Providing warm blankets in this situation is a simple yet effective intervention based on the understanding of postpartum shivering.

Correct Answer: B

Rationale: In this scenario, option B is the most appropriate nursing assessment. The mother's lack of experience in handling newborns is evident when she states that this is the first newborn she has ever held. While there is positive bonding as she holds the baby en face and strokes his cheek, the need for teaching related to newborn care is crucial to ensure the newborn's well-being. Option A is incorrect because even though there is positive bonding, teaching related to newborn care is necessary due to the mother's lack of experience. Option C is not appropriate as there is no indication of poor bonding or child abuse, simply a lack of experience. Option D is incorrect as it assumes poor bonding when the scenario only describes the mother's lack of experience. Educationally, this question highlights the importance of assessing a mother's comfort and knowledge in caring for her newborn. It emphasizes the nurse's role in providing education and support to ensure the well-being of both the mother and the newborn.

Correct Answer: B

Rationale: In the context of pharmacology and postpartum care, it is crucial for nurses to educate women about postpartum blues. Option B, which states that postpartum blues typically last about a week or two, is the correct answer. This information is important for the woman to understand that these feelings are temporary and usually resolve on their own without the need for medical intervention. Option A is incorrect because while it is true that the father may also experience emotional changes during the postpartum period, this information is not directly related to the discussion about postpartum blues. Option C is incorrect because medications are not typically needed to relieve the symptoms of postpartum blues, as it is a normal part of the postpartum experience. Option D is incorrect as postpartum blues are actually quite common, affecting a significant number of women after childbirth. Educationally, this question helps reinforce the importance of providing accurate and relevant information to women regarding their postpartum experience. Nurses play a vital role in supporting women through this period of adjustment, and by understanding the duration and nature of postpartum blues, they can better assist women in coping with these temporary emotional changes.

Correct Answer: C

Rationale: In this scenario, the most appropriate nursing diagnosis for the client experiencing sadness, frequent weeping, and expressing feeling terrible despite expecting happiness post-delivery is "Ineffective individual coping related to hormonal shifts" (Option C). This choice is correct because the client's symptoms align with postpartum depression, which is often caused by hormonal fluctuations after childbirth. The client's inability to cope effectively with these changes is evident in her emotional distress. Option A is incorrect because suicidal thoughts related to psychotic ideations would present with more severe symptoms beyond just feeling sad and weeping frequently. Option B is incorrect as there is no mention of a traumatic delivery in the scenario. Option D is incorrect as spiritual distress related to immature belief systems does not align with the client's symptoms of postpartum depression. Educationally, this question highlights the importance of recognizing and addressing postpartum depression, a common complication after childbirth. Nurses need to be aware of the signs and symptoms to provide appropriate support and interventions for new mothers experiencing emotional challenges during the postpartum period.

Correct Answer: B

Rationale: In this scenario, the correct question to ask the Seventh Day Adventist woman who delivered a baby boy by cesarean section is option B) "Is there anything special you will need for your Sabbath on Sunday?" This question is important because Seventh Day Adventists observe the Sabbath from Friday sunset to Saturday sunset and have specific dietary and religious practices during this time. By asking this question, the nurse shows cultural competence and respect for the patient's beliefs, ensuring that her religious needs are met during her hospital stay. Options A, C, and D are incorrect in this context because they do not address the specific religious beliefs and practices of Seventh Day Adventists. Option A assumes all Seventh Day Adventists follow a vegetarian diet, which is not universally true. Option C assumes the woman wants to schedule a baptism immediately after delivery, which may not align with her beliefs or practices. Option D is irrelevant as it pertains to the circumcision of the baby, not the mother's religious needs. Educationally, this question highlights the importance of cultural competence and patient-centered care in nursing practice. Understanding and respecting the religious beliefs and practices of patients is crucial for providing holistic care that meets their physical, emotional, and spiritual needs. By incorporating these aspects into nursing practice, nurses can establish trusting relationships with patients and promote positive health outcomes.