Nokea
A breastfeeding patient who was discharged yesterday calls to ask about a tender hard area on her right breast. What should the nurse's first response be?
- A. This is a normal response in breastfeeding mothers.'
- B. Notify your doctor so he can start you on antibiotics.'
- C. Stop breastfeeding because you probably have an infection.'
- D. Try massaging the area and apply heat; it is probably a plugged duct.'
Correct Answer: D
Rationale: The correct response is D because a tender, hard area on the breast is likely a plugged duct, which can be relieved by massaging the area and applying heat to promote milk flow. This approach helps prevent further complications and encourages continued breastfeeding.
Choice A is incorrect as it dismisses the patient's concern without providing helpful guidance. Choice B is incorrect because antibiotics are not typically necessary for a plugged duct unless it progresses to mastitis. Choice C is incorrect as stopping breastfeeding can worsen the condition and may lead to engorgement or mastitis.
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Edward, a newborn delivered at 41 weeks' gestation, weighs 10 lb 4 oz. Vaginal delivery for this G1P1 mother was assisted with forceps. The nurse is completing her assessment and notes a sharply demarcated swelling over the parietal bones. The occipital and frontal skull bones are not affected. The neck does not appear edematous and is soft to the touch with full mobility. The infant is awake and active and has been breast-feeding well. What is the most probable cause of the swelling?
- A. cephalohematoma
- B. subgaleal hemorrhage
- C. caput succedaneum
- D. skull fracture
Correct Answer: A
Rationale: Cephalohematoma involves localized bleeding beneath the periosteum, typically over a single bone.
Upon assessment, the RN notices that the newborn remains red at rest. Which laboratory value is most important for the nurse to evaluate?
- A. Glucose
- B. Bilirubin
- C. Sodium
- D. Hematocrit
Correct Answer: D
Rationale: The correct answer is D: Hematocrit. A red newborn at rest may indicate polycythemia, which increases the risk of hyperviscosity and complications. Hematocrit measures the percentage of red blood cells in the blood, so evaluating it can help determine if the newborn has polycythemia. Glucose (A) is important but not directly related to the newborn's redness. Bilirubin (B) is crucial for evaluating jaundice, not redness. Sodium (C) levels are not typically associated with a red newborn at rest.
A nurse is providing discharge instructions to a parent on preventing SIDS. What action by the parent signifies that they have effectively grasped what has been taught?
- A. The parent wraps the baby in layers of blankets.
- B. The parent puts several stuffed animals in the baby’s crib.
- C. The parent places the infant on the infant’s back to sleep.
- D. The parent sleeps or shares a bed with the infant.
Correct Answer: C
Rationale: Placing the infant on their back reduces SIDS risk.
A family who immigrated to the United States in the past year is preparing to take their infant home with both oxygen and G-tube feeds. How does the nurse know discharge education has prepared them for success?
- A. The caregiver has been able to demonstrate a G-tube feed successfully at the correct feeding times throughout the day.
- B. The caregiver was unable to safely administer all medications at the prescribed times during the day and night.
- C. The family has cultural concerns that have not been addressed at this time regarding home-going care for the infant, but a social worker has been consulted.
- D. Oral feeding is important to the caregiver for the infant, and they continue to attempt PO feedings after both the nurse and attending physician have explained the infant’s need for G-tube feedings.
Correct Answer: A
Rationale: Successful demonstration of G-tube feeding indicates preparedness.
When thinking about scoring an Apgar assessment, the nurse knows that grimace is an assessment of what in a newborn?
- A. Grimace is an assessment of a newborn's response to taking their first breath.
- B. Grimace is an assessment of the flexion of hips and legs in the newborn.
- C. Grimace is an assessment of the response to seeing their birthing person's face.
- D. Grimace is an assessment of the response to stimulation from the nurse.
Correct Answer: D
Rationale: The correct answer is D because the grimace in an Apgar assessment refers to the newborn's response to stimulation, such as a gentle pinch or suctioning. This response indicates the baby's reflexes and neurological function, which are important indicators of overall health. Choices A and C are incorrect because the grimace is not specifically related to breathing or visual stimuli. Choice B is incorrect because it refers to a different aspect of the assessment (muscle tone).