A nurse is providing teaching to a postpartum client about strategies to reduce the risk of newborn abduction from the facility.
Which of the following instructions should the nurse include in the teaching?

"Give your newborn only to staff members you recognize.”.

"Remove your newborn's microchip identification band after you have arrived home.”.

"Personally carry your newborn to the nursery if you need assistance.”.

"Bring your newborn in the bassinet into the bathroom with you.”.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Relying solely on facial recognition of staff members is an insufficient and potentially dangerous security measure. Hospital staff members can change shifts, and imposters might attempt to abduct newborns. Robust security protocols, such as mandatory identification badges and alarm systems on infant security tags, are designed to prevent unauthorized individuals from leaving the unit with an infant, providing a more reliable defense against abduction.

Choice B rationale

The instruction to remove a newborn's microchip identification band after arriving home is inaccurate and potentially misleading. Hospitals typically use infant security tags or bands that are removed by staff upon discharge, not by the parents at home. These bands are crucial for preventing abductions within the facility by triggering alarms if an infant is taken beyond designated boundaries.

Choice C rationale

Personally carrying a newborn to the nursery, especially without supervision or adherence to facility protocols, increases the risk of abduction. Hospitals often require staff to transport infants in bassinets or cribs, typically with two staff members present, to minimize opportunities for unauthorized individuals to gain access to or abduct a newborn. This procedure enhances infant safety significantly.

Choice D rationale

Bringing the newborn in the bassinet into the bathroom with the mother maintains constant direct observation and reduces the risk of abduction. This strategy minimizes the time the infant is left unattended, preventing opportunities for an abductor to seize the child. Maintaining proximity and direct line of sight is a fundamental principle of infant security in a hospital environment.

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

The nurse should first monitor the client’s fundal tone followed by the client’s heart rate.

Rationale for correct answers
Fundal tone is the primary indicator of uterine contractility. A boggy fundus that does not firm with massage indicates uterine atony, the most common cause of postpartum hemorrhage (PPH). Effective uterine contraction compresses uterine blood vessels to reduce bleeding. Monitoring fundal tone allows early identification of hemorrhage risk. Heart rate is a sensitive early sign of hypovolemia; a rising heart rate (tachycardia above 100 beats/min) reflects compensatory response to blood loss before blood pressure drops. Normal adult heart rate ranges from 60 to 100 beats/min; an increase indicates circulatory stress.

Rationale for incorrect answers
Bruising to perineal area (A) is important but secondary; it does not directly assess bleeding severity or uterine status. Pain level (C) is subjective and can be influenced by many factors; it does not reliably indicate hemorrhage. Uterine height (D) measures fundal location but does not assess firmness or tone, which are critical for detecting atony. Temperature (B) changes are not immediate indicators of bleeding. Pain level (C) and uterine height (D) similarly lack specificity for hemorrhage assessment compared to fundal tone and heart rate.

Take home points

Fundal tone assessment is critical for early detection of uterine atony causing postpartum hemorrhage.
Tachycardia is an early physiological sign of hypovolemia and should be closely monitored.
Perineal bruising and pain are secondary findings and less specific to hemorrhage severity.
Uterine height and temperature changes do not reliably indicate acute hemorrhage status.

A. "It is important to gain 2 pounds per week throughout the rest of your pregnancy.”. B. "You can cause problems for your baby if you try to diet while pregnant.”. C. "It would be helpful for us to meet with the dietitian to see how they can help you meet and assess your nutritional needs.”. D. "You should eat an additional 700 calories per day while you are pregnant.”.

Correct Answer is C

Explanation

Choice A rationale

While weight gain is crucial during pregnancy, a blanket statement of 2 pounds per week is not universally appropriate. The recommended rate of weight gain varies based on the client's pre-pregnancy BMI and the trimester. Excessive or insufficient weight gain can lead to adverse maternal and fetal outcomes, including macrosomia or intrauterine growth restriction, highlighting the need for individualized nutritional guidance rather than a fixed weekly gain.

Choice B rationale

Dieting during pregnancy, especially restrictive calorie intake, can significantly compromise the nutrient supply to the developing fetus. Fetal growth and organogenesis are highly dependent on adequate maternal nutritional stores and daily nutrient intake. Inadequate nutrition can lead to low birth weight, premature birth, and long-term health complications for the infant, emphasizing the dangers of unguided dietary restrictions.

Choice C rationale

A dietitian possesses specialized knowledge in medical nutrition therapy and can provide personalized recommendations based on the adolescent's specific nutritional needs, gestational age, and pre-pregnancy weight. This collaborative approach ensures optimal maternal and fetal health by addressing any deficiencies, managing appropriate weight gain, and promoting healthy eating habits throughout the pregnancy, which is crucial for adolescent development and pregnancy outcomes.

Choice D rationale

The caloric needs of a pregnant adolescent increase in the second and third trimesters, but a fixed additional 700 calories per day may not be accurate for all individuals. Caloric requirements are dynamic and depend on pre-pregnancy weight, activity level, and the specific stage of gestation. Overestimation can lead to excessive weight gain, while underestimation can result in inadequate fetal growth, necessitating individualized assessment.

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A nurse is providing teaching to a postpartum client about strategies to reduce the risk of newborn abduction from the facility. Which of the following instructions should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a female client who is in the fourth stage of labor in the postpartum unit. Complete the following sentence by using the list of options. The nurse should first monitor the client’s ________ followed by the client’s __________.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

A nurse is caring for an adolescent client who is at 24 weeks of gestation. The client's prepregnancy weight was within the recommended range for their height and they have gained 2.7 kg (6 lb) during the pregnancy. Which of the following statements should the nurse make?

Correct Answer is C

Explanation

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A nurse is providing teaching to a postpartum client about strategies to reduce the risk of newborn abduction from the facility.
Which of the following instructions should the nurse include in the teaching?