Nokea
A breastfeeding client calls her obstetrician stating that her baby was diagnosed with thrush and that her breasts have become infected as well. Which of the following organisms has caused the baby's and mother's infection?
- A. Staphylococcus aureus.
- B. Streptococcus pneumoniae.
- C. Escherichia coli.
- D. Candida albicans.
Correct Answer: D
Rationale: Candida causes thrush.
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A gestational diabetic client, who delivered yesterday, is currently on the postpartum unit. Which of the following statements is appropriate for the nurse to make at this time?
- A. Monitor your blood glucose five times a day until your 6-week checkup.
- B. I will teach you how to inject insulin before you are discharged.
- C. Daily exercise will help to prevent you from becoming diabetic in the future.
- D. Your baby should be assessed every 6 months for signs of juvenile diabetes.
Correct Answer: A
Rationale: Gestational diabetes often resolves after delivery, but monitoring is still important.
A nurse on the postpartum unit is caring for two postoperative cesarean clients. One client had spinal anesthesia for the delivery and the other client had an epidural. Which of the following complications will the nurse monitor the spinal client for that the epidural client is much less high risk for?
- A. Pruritus.
- B. Nausea.
- C. Postural headache.
- D. Respiratory depression.
Correct Answer: C
Rationale: Spinal anesthesia increases the risk of postural headaches.
A neonate is admitted to the nursery. The nurse makes the following assessments: weight 3,845 grams, head circumference 35 cm, chest circumference 33 cm, positive Ortolani sign, and presence of supernumerary nipples. Which of the assessments should be reported to the health care practitioner?
- A. Birth weight.
- B. Head and chest circumferences.
- C. Ortolani sign.
- D. Supernumerary nipples.
Correct Answer: C
Rationale: Positive Ortolani sign indicates hip instability and requires medical evaluation.
The postpartum person asks for only warm drinks and food. How can the nurse support this cultural tradition?
- A. Explain that nurses do not have control over the food.
- B. Tell the person that cold fluids are better for recovery.
- C. Instruct the person to call the nurse to warm up food or drink.
- D. Educate the person on culture in the United States.
Correct Answer: C
Rationale: Rationale for Correct Answer (C): Instructing the person to call the nurse to warm up food or drink is the best way to support the cultural tradition of consuming warm drinks and food. This option respects the individual's cultural preferences and provides a practical solution to meet their needs without imposing personal opinions. By offering assistance in warming up the food or drink, the nurse acknowledges and honors the person's cultural background, promoting a culturally sensitive and patient-centered approach.
Summary of Incorrect Choices:
A: Explaining that nurses do not have control over the food dismisses the person's request and does not address the cultural tradition.
B: Telling the person that cold fluids are better for recovery disregards the cultural preference for warm drinks and food.
D: Educating the person on culture in the United States is not relevant to supporting their specific cultural tradition of consuming warm drinks and food.
Four newborns are in the neonatal nursery, none of whom is crying or in distress. Which of the babies should the nurse report to the neonatologist?
- A. 16-hour-old baby who has yet to pass meconium.
- B. 16-hour-old baby whose blood glucose is 50 mg/dL.
- C. 2-day-old baby who is breathing irregularly at 70 breaths per minute.
- D. 2-day-old baby who is excreting a milky discharge from both nipples.
Correct Answer: C
Rationale: Irregular breathing at 70 breaths per minute could indicate respiratory distress and requires further evaluation.