The nurse takes a newborn to a primipara for a feeding. The mother holds the baby en face, strokes his cheek, and states that this is the first newborn she has ever held. Which of the following nursing assessments is most appropriate?

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: 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.

Correct Answer: C

Rationale: In the context of postpartum care, the correct assessment to be made before administering Methergine (ergonovine) is blood pressure (Option C). Methergine is a uterotonic medication commonly used to prevent or treat postpartum hemorrhage by causing uterine contractions. Monitoring blood pressure is crucial because Methergine can cause hypertension as a side effect. By assessing blood pressure before administration, healthcare providers can ensure that the patient's blood pressure is within safe limits to receive the medication. Option A (Apical pulse) is not the primary assessment needed before administering Methergine because the medication's effect on blood pressure is more critical in this context. Option B (Lochia flow) and Option D (Episiotomy) are not directly related to the administration of Methergine and do not impact the safety or efficacy of the medication. In an educational context, understanding the rationale behind assessing blood pressure before administering specific medications is essential for providing safe and effective patient care. By emphasizing the importance of monitoring vital signs and understanding the potential side effects of medications like Methergine, healthcare professionals can ensure they are administering treatments responsibly and minimizing risks to their patients during the postpartum period.

Correct Answer: A

Rationale: In the context of pharmacology, Methergine (ergonovine) is commonly used to prevent or control postpartum hemorrhage by causing uterine contractions. The correct side effect to warn a client about when receiving Methergine is a headache. This is because Methergine can cause vasoconstriction, which may lead to increased blood pressure and subsequent headaches. Regarding the incorrect options: - Nausea is a common side effect of Methergine but it is not the primary side effect that the client should be warned about. - Cramping is expected with the use of Methergine as it causes uterine contractions to prevent hemorrhage. - Fatigue is not typically associated with Methergine use and is not a significant side effect to warn the client about in this scenario. Educationally, it is important for nurses to understand the specific side effects of medications to effectively educate clients on what to expect and how to manage them. By providing accurate information, nurses can enhance patient safety and promote better adherence to treatment regimens.