A nurse is caring for a client who is postpartum. The nurse should recognize which of the following statements by the client as a possible indicator of inhibition of parental attachment?
"I don't need the bath demonstration. I know how to do it.".
"Do you think you could keep him in the nursery for the next feeding so I can get some sleep?.".
"I just wish he had more hair. I'm going to have to keep a hat on his head till he grows some.".
"He's got my husband's nose, that's for sure.".
The Correct Answer is C
Choice A reason:
This statement does not indicate inhibition of parental attachment. The client may have prior experience or knowledge of bathing a newborn and may not need the demonstration. The nurse should respect the client's autonomy and confidence in this skill.
Choice B reason:
This statement does not indicate inhibition of parental attachment. The client may be exhausted from the labor and delivery process and may need some rest to recover. The nurse should support the client's request and ensure that the newborn is well cared for in the nursery.
Choice C reason:
This statement indicates inhibition of parental attachment. The client expresses dissatisfaction with the newborn's appearance and implies that the newborn is not attractive enough. The nurse should explore the client's feelings and expectations about the newborn and provide reassurance and education about normal variations in newborn features.
Choice D reason:
This statement does not indicate inhibition of parental attachment. The client recognizes a family resemblance in the newborn and expresses a positive connection with the newborn and the partner. The nurse should acknowledge the client's observation and encourage further bonding with the newborn.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
This is a caput succedaneum, which is a collection of fluid from pressure of the vacuum extractor. This is the correct answer because caput succedaneum is a swelling of the scalp that crosses the suture line and is caused by prolonged pressure on the baby's head during delivery. It can also result from the use of vacuum extraction or forceps. Caput succedaneum is harmless and usually resolves on its own within a few days.
Choice B reason:
This is erythema toxicum, which is a transient allergic reaction that causes edema in the skin. This is incorrect because erythema toxicum is a common rash that affects newborns, but it does not cause swelling of the scalp or cross the suture line. It appears as red blotches with small white or yellow bumps that can occur anywhere on the body. Erythema toxicum is also harmless and usually disappears within a week.
Choice C reason:
This is a cephalhematoma, which will resolve on its own in 3 to 5 days. This is incorrect because cephalhematoma is bleeding under the scalp that does not cross the suture line and is caused by ruptured blood vessels in the scalp. It can also result from the use of vacuum extraction or forceps. Cephalhematoma may take weeks or months to resolve and can increase the risk of jaundice.
Choice D reason:
This is a Mongolian spot, which is found on many newborns. This is incorrect because Mongolian spots are bluish-gray patches of skin that are present at birth and are caused by melanocytes (pigment-producing cells) that are trapped in the deeper layers of the skin. They are not related to swelling or pressure on the head and usually fade by age 5.
Correct Answer is A
Explanation
Choice A reason:
Maternal/newborn blood group incompatibility is the most common cause of pathologic jaundice, which appears within the first 24 hours of life. This occurs when the mother's antibodies attack the newborn's red blood cells, causing hemolysis and increased bilirubin production. The excess bilirubin causes the yellowish discoloration of the skin and mucous membranes.
Choice B reason:
The absence of vitamin K is not related to jaundice but to hemorrhagic disease of the newborn. Vitamin K is essential for blood clotting and is given to newborns as an injection shortly after birth. Newborns are at risk of vitamin K deficiency because they have low levels of vitamin K in their bodies and breast milk, and their intestinal bacteria are not yet able to synthesize vitamin K.
Choice C reason:
Maternal cocaine abuse can cause many complications for the newborn, such as prematurity, low birth weight, neonatal abstinence syndrome, neurobehavioral problems, and congenital anomalies. However, it is not a direct cause of jaundice in the newborn.
Choice D reason:
Physiologic jaundice is a normal and benign condition that affects about 60% of term newborns. It occurs due to the immature liver's inability to metabolize bilirubin effectively. It usually appears after the first 24 hours of life and peaks around the third or fourth day. It does not require treatment unless the bilirubin level is very high or rising rapidly.
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