The postpartum nurse is planning a home visit to a mother who delivered her baby 1 week ago. Which finding indicates to the nurse a possible problem with mother–infant bonding?

Correct Answer: C

Rationale: The correct answer is C because when a mother primarily focuses on her physical recovery and concerns during a home visit, it may indicate a possible problem with mother-infant bonding. This is because bonding involves emotional connection, interaction, and care between the mother and baby, which goes beyond physical recovery. A: The mother being pleased to have the nurse visit her home and baby is a positive sign of engagement and interest in the baby's well-being. B: The baby's grandmother being present and involved with mother/baby care can actually enhance bonding by providing support and assistance. D: The baby's father being on 'paternity leave' and involved with the baby is another positive sign of family support and involvement in bonding.

Correct Answer: B

Rationale: The correct answer is B because rubella vaccine is a live attenuated vaccine, which means it should not be given to pregnant women as it can potentially harm the fetus. Therefore, it is important for the postpartum woman to avoid becoming pregnant after receiving the vaccine to prevent any risks to future pregnancies. Choice A is incorrect as breastfeeding is not contraindicated with the rubella vaccine. Choice C is incorrect because the rubella vaccine should not be given to individuals with severe egg allergies. Choice D is incorrect as there is no need for the woman to be separated from her infant after receiving the rubella vaccine.

Correct Answer: B

Rationale: The correct answer is B: The woman has an episiotomy. A sitz bath is often recommended postpartum for women who have had an episiotomy to promote healing and relieve discomfort. An episiotomy is a surgical incision made in the perineum during childbirth to facilitate delivery and prevent tearing. The warm water in a sitz bath helps to reduce swelling, promote circulation, and clean the area. Incorrect choices: A: The woman is multiparous - Multiparity does not directly correlate with the need for a sitz bath postpartum. C: The woman had a vaginal birth - While this is true, it does not specifically address the need for a sitz bath. D: The woman received a pudendal block for anesthesia - Although this information may be relevant to the birth experience, it does not directly relate to the need for a sitz bath postpartum.

Correct Answer: C

Rationale: The correct answer is C because the statement "Where did he get those long fingers?" indicates a lack of recognition or acceptance of the newborn's physical characteristics, which may suggest a disconnect or lack of bonding between the mother and the baby. This statement does not show the mother identifying any physical traits of herself in the baby, unlike choices A and B. Choice D is a common concern among new parents and does not necessarily indicate ineffective bonding. In summary, choice C is correct as it demonstrates a potential lack of bonding based on the mother's statement about the baby's physical features, while the other choices do not indicate the same level of concern.

Correct Answer: C

Rationale: The correct answer is C: Ask the patient to void. This action is performed prior to assessing the patient's uterus because a full bladder can displace the uterus, leading to inaccurate assessment of uterine size and position. By asking the patient to void, the nurse ensures an accurate assessment of the uterus. Placing the patient on the left side (choice A) is important for preventing supine hypotension but is not directly related to assessing the uterus. Assessing the passage of lochia (choice B) is important postpartum, but it can be done after checking the uterus. Administering a dose of oxytocin (choice D) may be indicated to prevent postpartum hemorrhage, but it is not the first step in assessing the patient's uterus.