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 the mother focusing the visit on her physical recovery and concerns suggests a lack of emotional connection or bonding with the baby. This could indicate a potential problem with mother-infant bonding. Choice A is incorrect because the mother being pleased to have the nurse visit her home and baby shows positive engagement. Choice B is incorrect because the baby's grandmother being present and involved with mother/baby care indicates social support and family involvement, which can enhance bonding. Choice D is incorrect because the baby's father being on 'paternity leave' and involved with the baby also demonstrates active participation in caregiving and bonding activities.

Correct Answer: B

Rationale: The correct answer is B because rubella vaccine contains live attenuated virus, which can pose a risk to a developing fetus if the woman becomes pregnant shortly after vaccination. This information is crucial for the woman to avoid pregnancy for a certain period after receiving the vaccine. Choice A is incorrect because breastfeeding is not contraindicated after receiving the rubella vaccine. Choice C is incorrect because the rubella vaccine should not be given to individuals with a severe allergy to eggs. Choice D is incorrect because 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 because having an episiotomy is directly related to the need for a sitz bath postpartum. An episiotomy is a surgical incision made in the perineum during childbirth to enlarge the vaginal opening, which can cause discomfort and swelling postpartum. A sitz bath helps to soothe and cleanse the area, promote healing, and reduce the risk of infection. Choice A (The woman is multiparous) is incorrect as the number of pregnancies does not directly correlate with the need for a sitz bath. Choice C (The woman had a vaginal birth) is incorrect because all women who give birth vaginally can benefit from a sitz bath, not just this woman specifically. Choice D (The woman received a pudendal block for anesthesia) is incorrect as the type of anesthesia used does not determine the need for a sitz bath; it is more related to the presence of an episiotomy.

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 traits, which could suggest a disconnect between the mother and infant. This statement may signal that the mother is not bonding effectively with the baby. In contrast, choices A, B, and D all demonstrate a degree of recognition or concern for the baby's physical characteristics or behaviors, which are more indicative of normal bonding behaviors between a mother and newborn.

Correct Answer: C

Rationale: The correct answer is C: Ask the patient to void. This is important prior to assessing the patient's uterus because a full bladder can displace the uterus and make it difficult to accurately assess its position and firmness. By asking the patient to void, the nurse ensures a more accurate assessment of the uterus. Placing the patient on the left side (A) is a position used to maximize uterine perfusion but is not necessary prior to assessing the uterus. Assessing the passage of lochia (B) is important but can be done after assessing the uterus. Administering oxytocin (D) may be indicated to help prevent postpartum hemorrhage but is not necessary prior to assessing the uterus.