Nokea
A nurse is providing discharge teaching to a postpartum client about caring for her five-day-old male newborn at home.
- A. Retract the foreskin to clean your baby's penis during each bath
- B. Use triple antibiotic ointment on your baby's umbilical cord twice per day
- C. Swaddle your baby tightly with legs extended before laying him down to sleep
- D. Notify your baby's pediatrician if he urinates less than 6 times per day
Correct Answer: D
Rationale: The correct answer is D: Notify your baby's pediatrician if he urinates less than 6 times per day. This is important because adequate urine output is a sign of good hydration and kidney function in newborns. Notifying the pediatrician if the baby urinates less than 6 times a day can help identify any potential issues early on.
Choice A is incorrect because retracting the foreskin to clean the baby's penis is not recommended as it can lead to infections.
Choice B is incorrect because using triple antibiotic ointment on the umbilical cord is not necessary and can actually delay healing.
Choice C is incorrect because swaddling the baby tightly with legs extended can increase the risk of hip dysplasia.
Overall, it is important to focus on monitoring the baby's urine output and notifying the pediatrician if there are any concerns.
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A nurse is observing an adolescent client who is offering her newborn a bottle while he is laying in the bassinet. When the nurse offers to pick the newborn up and place them in the client's arms, the mother states 'No, the baby is too tired to be held.' Which of the following actions should the nurse take?
- A. Insist that the mother pick up the newborn to feed him
- B. Demonstrate how to hold a newborn and allow the client to practice
- C. Persuade the client to breastfeed the newborn to promote bonding
- D. Offer to take the newborn to the nursery to finish his feeding
Correct Answer: B
Rationale: The correct answer is B: Demonstrate how to hold a newborn and allow the client to practice. This option respects the mother's decision while also providing education and support. By demonstrating proper newborn holding techniques and allowing the client to practice, the nurse can ensure the baby's safety and promote bonding between the mother and newborn. Insisting on the mother picking up the newborn (choice A) goes against her wishes and may create tension. Persuading the client to breastfeed (choice C) may not be feasible or appropriate at that moment. Taking the newborn to the nursery (choice D) may not align with the mother's preferences.
A nurse on a labor and delivery unit is receiving infection control standards with a newly licensed nurse. The nurse should instruct the newly licensed nurse to don gloves for which of the following procedures?
- A. Assisting a mother with breastfeeding
- B. Performing a newborn’s initial bath
- C. Administering the measles, mumps, rubella vaccine
- D. Performing umbilical cord care
Correct Answer: D
Rationale: The correct answer is D: Performing umbilical cord care. Gloves should be worn when performing any procedure that involves contact with bodily fluids or potentially infectious material, such as blood or bodily secretions. Umbilical cord care may involve cleaning the area, which can have potential exposure to bodily fluids. The other choices (A, B, C) do not involve direct contact with bodily fluids or infectious material, so gloves are not necessary for those procedures. It is important to maintain infection control practices to prevent the spread of infections in the healthcare setting.
A nurse is preparing to perform a fundal massage for a postpartum client with hearing seeing uterine atony. In which order should the nurse plan to perform the following actions? (molded steps into the box on the right. Placing them in order of performance use all steps)
- A. Ask the client to lie on her back with her knees flexed
- B. Position one hand around the top of the client's fundus and one hand just above the client's symphysis pubis
- C. Rotate the upper hand to massage the client's uterus while using slight downward pressure to compress the fundus
- D. Observe the client's perineum for the passage of clots and the amount of bleeding
Correct Answer: A,B,C.D
Rationale: The correct order for performing fundal massage is A, B, C, and D. First, asking the client to lie on her back with knees flexed (A) allows for proper positioning. Then, positioning one hand around the top of the fundus and one hand above the symphysis pubis (B) ensures correct placement for the massage. Next, rotating the upper hand to massage the uterus while applying slight downward pressure (C) facilitates uterine contractions. Finally, observing the perineum for clots and bleeding (D) helps monitor postpartum hemorrhage. Choices E, F, and G are not applicable to the process of performing a fundal massage and are therefore incorrect.
A nurse is caring for a client who is experiencing sore nipples from breastfeeding. Which of the following actions should the nurse take?
- A. Place a snug dressing on the client’s nipple when not breastfeeding
- B. Ensure the newborn’s mouth is wide open before latching to the breast
- C. Encourage the client to limit the newborn’s feeding to 10 min on each breast
- D. Instruct the client to begin the feeding with the nipple that is most tender
Correct Answer: B
Rationale: The correct answer is B: Ensure the newborn’s mouth is wide open before latching to the breast. This is the correct action to take to address sore nipples from breastfeeding. Ensuring a wide latch helps the baby to properly attach to the breast, reducing the pressure on the nipple and preventing further damage. A snug dressing (Option A) can worsen the condition by obstructing airflow and promoting moisture. Limiting feeding time (Option C) can lead to inadequate milk supply or poor weight gain. Starting with the most tender nipple (Option D) can prolong healing.
A nurse is caring for four antepartum clients. Which of the following clients should the nurse assess first?
- A. A client who is at 7 weeks of gestation and reports urinary frequency
- B. A client who is at 32 weeks of gestation and reports seeing floating spots
- C. A client who is 38 weeks of gestation and reports leg cramps
- D. A client who is at 20 weeks of gestation and reports periodic numbness in her fingers
Correct Answer: B
Rationale: The correct answer is B. The nurse should assess the client who is at 32 weeks of gestation and reports seeing floating spots first. Seeing floating spots could be a sign of preeclampsia, a serious pregnancy complication characterized by high blood pressure and organ damage. Preeclampsia can lead to severe complications for both the mother and the baby if not managed promptly. Therefore, this client needs immediate assessment to rule out preeclampsia and ensure appropriate interventions are initiated. Choices A, C, and D do not present with urgent signs or symptoms that require immediate attention compared to the potential severity of preeclampsia in choice B.