Nokea
A baby boy is to be circumcised by the mother's obstetrician. Which of the following actions shows that the nurse is being a patient advocate?
- A. Before the procedure
- B. the nurse prepares the sterile field for the physician.
- C. The nurse refuses to unclothe the baby until the doctor orders something for pain.
- D. The nurse holds the feeding immediately before the circumcision.
Correct Answer: B
Rationale: Ensuring pain management demonstrates advocacy for the baby's comfort and safety.
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The nurse is evaluating the effectiveness of an intervention when assisting a woman whose baby has been latched to the nipple only rather than to the nipple and the areola. Which response would indicate that further intervention is needed?
- A. The client states that the pain has decreased.
- B. The nurse hears the baby swallow after each suck.
- C. The baby's jaws move up and down once every second.
- D. The baby's cheeks move in and out with each suck.
Correct Answer: C
Rationale: Rapid jaw movements without swallowing suggest ineffective feeding.
A postpartum patient calls the clinic and reports to the nurse feelings of fatigue, tearfulness, and anxiety. What is the nurse’s most appropriate response at this time?
- A. “When did these symptoms begin?”
- B. “Sounds like normal postpartum depression.”
- C. “Are you having trouble getting enough sleep?”
- D. “Are you able to get out of bed and provide care for your baby?”
Correct Answer: A
Rationale: The correct answer is A: "When did these symptoms begin?" The nurse's response should address the patient's concerns and gather more information to assess the situation accurately. By asking when the symptoms began, the nurse can determine the duration and severity of the symptoms, enabling appropriate intervention.
Choice B is incorrect because assuming the symptoms are due to "normal postpartum depression" without further assessment is premature and may overlook other potential causes. Choice C focuses solely on sleep and may not address the underlying issues causing the patient's symptoms. Choice D assumes the patient's ability to provide care for the baby without first addressing the patient's emotional well-being.
When assessing the A of the acronym REEDA, the nurse should evaluate the
- A. skin color.
- B. degree of edem
- C. edges of the episiotomy.
- D. episiotomy for discharg
Correct Answer: C
Rationale: The correct answer is C. When assessing the A of REEDA (Redness, Edema, Ecchymosis, Discharge, and Approximation) in wound assessment, nurses should evaluate the edges of the episiotomy. This is important to ensure proper healing and closure of the incision site. Evaluating skin color (A) is important for overall wound assessment but not specifically for the edges of the episiotomy. Edema (B) refers to swelling, which is important to monitor but not specific to the edges of the episiotomy. Checking the episiotomy for discharge (D) is relevant for the "D" component of REEDA but not for the "A" component, which specifically focuses on the edges of the incision.
A breastfeeding woman, 6 weeks postdelivery, must go into the hospital for a hemorrhoidectomy. Which of the following is the best intervention regarding infant feeding?
- A. Have the woman wean the baby to formula.
- B. Have the baby stay in the hospital room with the mother.
- C. Have the woman pump and dump her milk for two weeks.
- D. Have the baby bottle fed milk that the mother has stored.
Correct Answer: D
Rationale: Stored milk ensures continued breastfeeding.
What is the nursing intervention for unilateral edema in a lower extremity and a hot, red area on the leg?
- A. Contact the health-care provider.
- B. Explain this is a normal finding.
- C. Massage calf.
- D. Offer pain medication.
Correct Answer: A
Rationale: The correct answer is A: Contact the health-care provider. Unilateral edema along with a hot, red area on the leg can indicate a potential serious condition such as deep vein thrombosis (DVT). It is crucial to involve the healthcare provider immediately for further evaluation and treatment. Contacting the healthcare provider ensures timely diagnosis and appropriate management.
Summary:
B: Explaining this as a normal finding is incorrect as it could be a sign of a serious condition.
C: Massaging the calf can potentially dislodge a clot in case of DVT, leading to severe complications.
D: Offering pain medication without proper evaluation can mask the symptoms and delay necessary medical intervention.