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A breastfeeding client, 6 days postdelivery, calls the postpartum unit stating, “I think I am engorged. My breasts are very hard and hot and they really hurt.” Which of the following questions should the nurse ask at this time?
- A. “Have you taken a warm shower this morning?”
- B. “Do you have an electric breast pump?”
- C. “How much did you have to drink yesterday?”
- D. “When was the last time you fed the baby?”
Correct Answer: D
Rationale: Asking when the client last fed the baby helps determine if engorgement is due to infrequent feeding, which is a common cause of breast engorgement.
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Which is the method of childbirth that helps prevent the fear-tension-pain cycle by using slow abdominal breathing in early labor and rapid chest breathing in advanced labor?
- A. Bradley
- B. Lamaze
- C. Leboyer
- D. Dick-Read
Correct Answer: D
Rationale: The correct answer is D: Dick-Read method. This method emphasizes relaxation and controlled breathing to reduce fear and pain during childbirth. Slow abdominal breathing in early labor helps maintain calmness, while rapid chest breathing in advanced labor assists in coping with intense contractions. The Dick-Read method's focus on the mind-body connection and natural childbirth aligns with preventing the fear-tension-pain cycle.
Summary:
A: Bradley method emphasizes partner-coached childbirth.
B: Lamaze method focuses on breathing techniques and relaxation.
C: Leboyer method emphasizes gentle birthing practices.
These choices do not specifically address the fear-tension-pain cycle with the same breathing techniques as the Dick-Read method.
A pregnant woman is complaining of ptyalism. The nurse should teach the woman to try which of the following self-care measures?
- A. Use an astringent mouthwash.
- B. Elevate her legs frequently.
- C. Eat high-fiber foods.
- D. Void when the urge is felt.
Correct Answer: A
Rationale: Ptyalism, or excessive salivation, can be managed with astringent mouthwash to reduce saliva production.
A 6-month-old child has been diagnosed with a significant hearing loss. Which of the following complications that occurred immediately after delivery could have resulted in this condition?
- A. Necrotizing enterocolitis.
- B. Hypoglycemia.
- C. Bronchopulmonary dysplasia.
- D. Kernicterus.
Correct Answer: D
Rationale: Kernicterus, caused by severe jaundice, can lead to hearing loss due to bilirubin toxicity in the brain.
A gravida 1 patient at 32 weeks of gestation reports that she has severe lower back pain. What should the nurse's assessment include?
- A. Palpation of the lumbar spine
- B. Exercise pattern and duration
- C. Observation of posture and body mechanics
- D. Ability to sleep for at least 6 hours uninterrupted
Correct Answer: C
Rationale: The correct answer is C. Observation of posture and body mechanics is essential in assessing lower back pain in a pregnant patient to identify any potential causes related to the growing uterus and changes in body mechanics. Palpation of the lumbar spine (Choice A) may provide some information but does not address the underlying issue. Exercise pattern and duration (Choice B) are important but not the priority in this scenario. Ability to sleep for at least 6 hours uninterrupted (Choice D) is not directly related to assessing lower back pain.
What patient symptom at 10 weeks of gestation requires further investigation by the nurse?
- A. breast tenderness
- B. infrequent nausea
- C. change in appetite
- D. weight loss
Correct Answer: D
Rationale: The correct answer is D: weight loss. At 10 weeks of gestation, weight loss is concerning as it may indicate potential issues like hyperemesis gravidarum or inadequate nutrition, posing risks to both the mother and fetus. Breast tenderness (A), infrequent nausea (B), and changes in appetite (C) are common symptoms during early pregnancy and may not necessarily indicate serious problems. Weight loss (D) should be investigated promptly to ensure the well-being of both the mother and the developing baby.