The nurse is performing a postpartum home care visit. Which ...

[bcretired]

The nurse is performing a postpartum home care visit. Which teaching has the highest priority?
 
  1. Teach or review how to bathe the baby.
  2. Teaching how to thoroughly child-proof the house
  3. How many wet diapers the baby should have daily
  4. Prevention of deformational plagiocephaly

Question 2

A young adolescent is transferred to the Labor and Delivery unit from the Emergency Department. The client is in active labor, but did not know that she was pregnant. The most important nursing action is to:
 
  1. Determine who might be the father of the baby for paternity testing.
  2. Ask the client what kind of birthing experience she would like to have.
  3. Assess blood pressure and check for proteinuria.
  4. Obtain a Social Services referral to discuss adoption.

[ynlevi]

Answer to Question 1

3
Rationale:
1. Although knowing how to bathe a newborn is important, adequate hydration is a higher priority.
2. Child-proofing the home is not necessary until the baby begins to crawl. This is a low priority at this time.
3. Wet diapers are an indication of hydration of the newborn. This is the highest priority.
4. Preventing flat spots on the back or side of the head is primarily a cosmetic issue. Hydration is a higher priority.

Answer to Question 2

3
Rationale:
1. Paternity testing is a lower priority than the physiologic well-being of the client and fetus.
2. A client with a previously undiagnosed pregnancy is unlikely to have given any thought to childbearing preferences.
3. Pre-eclampsia is more common among adolescents than in young adults, and is potentially life-threatening to both mother and fetus. This assessment is the highest priority.
4. During labor is an inappropriate time to discuss adoption or parenting. Wait until after the birth to have this discussion when dealing with an adolescent who did not know she was pregnant prior to the onset of labor.

[bcretired]

Gracias!

[Alyson.hiatt@yahoo.com]

TYSM