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A new mother asks the LPN/LVN, 'How do I know that my daughter is getting enough breast milk?' Which explanation should the nurse provide?
- A. Weigh the baby daily, and if she is gaining weight, she is eating enough.
- B. Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day.
- C. Offer the baby extra bottle milk after her feeding, and see if she is still hungry.
- D. If you're concerned, you might consider bottle feeding so that you can monitor her intake.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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What action should be implemented when preparing to measure the fundal height of a pregnant client?
- A. Have the client empty her bladder.
- B. Request the client lie on her left side.
- C. Perform Leopold's maneuvers first.
- D. Give the client some cold juice to drink.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Upon arrival in the nursery, a newborn infant is breathing satisfactorily but appears dusky. What action should the LPN/LVN take first?
- A. Notify the healthcare provider immediately.
- B. Suction the infant's nares, then the oral cavity.
- C. Check the infant's oxygen saturation rate.
- D. Position the infant on the right side.
Correct Answer: C
Rationale: The priority action in this scenario is to check the infant's oxygen saturation rate. This will provide crucial information on the infant's oxygen levels and the need for immediate oxygen therapy. Assessing oxygen saturation is essential in determining the severity of hypoxia and guiding further interventions to ensure adequate oxygenation.
A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue, and a moist cough. Which question is most important for the LPN/LVN to ask this client?
- A. Which symptom did you experience first?
- B. Are you eating large amounts of salty foods?
- C. Have you visited a foreign country recently?
- D. Do you have a history of rheumatic fever?
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client is admitted in active labor with a cervix that is 3 cm dilated, 50% effaced, and the presenting part at 0 station. An hour later, the client expresses the need to go to the bathroom. Which action should the nurse implement first?
- A. Palpate the client's bladder.
- B. Check the pH of the vaginal fluid.
- C. Review the fetal heart rate pattern.
- D. Determine cervical dilation.
Correct Answer: D
Rationale: The nurse should prioritize determining cervical dilation as it helps in assessing the progress of labor and ensures it is safe for the client to move. Changes in cervical dilation may indicate the advancement of labor, warranting appropriate interventions or restrictions on movement to prevent complications.
The nurse is caring for a one-year-old child following surgical correction of hypospadias. Which nursing action has the highest priority?
- A. Monitor urinary output
- B. Auscultate bowel sounds
- C. Observe appearance of stool
- D. Record percent of diet consumed
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.