Nokea
A breastfeeding mother is being discharged with her 2-day-old,full-term newborn. The nurse recognizes that the mother understands how to determine if her newborn is getting enough breast milk when making which statement?
- A. “He should have at least three wet diapers tomorrow.”
- B. “He should have one stool per day during the next week.”
- C. “At his 1-week checkup,he should weigh an additional 8 ounces.”
- D. “He should nurse for 5 minutes on each breast to get enough milk.”
Correct Answer: A
Rationale: A 3-day-old should have at least three wet diapers indicating adequate intake. Breastfed infants stool 3–10 times daily lose 5–10% birth weight initially and nurse 10–20 minutes per breast.
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The nurse completes teaching in preparation to discharge a mother and her 48-hour-old,full-term newborn. The nurse determines there is a need for further instruction about infant car safety when the newborn’s father is overheard making which statement?
- A. “We need to face the infant car seat toward the back of the car.”
- B. “I disarmed one front seat air bag so we can put the car seat in the front seat.”
- C. “Let’s check the car seat to make sure it will position the baby at a 45-degree angle.”
- D. “I know the baby will need to be in the infant car seat until he is over 20 pounds.”
Correct Answer: B
Rationale: The rear seat is safest for infants; air bags should not be disarmed for front-seat placement. Rear-facing 45-degree angle and car seat use until 20 lb are correct.
Which activity is most appropriate for the child with juvenile rheumatoid arthritis?
- A. Skipping rope
- B. Softball
- C. Swimming
- D. Running
Correct Answer: C
Rationale: Swimming is a low-impact activity that promotes joint mobility and muscle strength without stressing inflamed joints, making it ideal for a child with JRA.
Which finding documented by the nurse is most indicative of a client with rheumatic fever?
- A. Slow, irregular heartbeat
- B. Blotchy, diffuse erythema
- C. Decreased antistreptolysin O titer (ASO titer)
- D. Generalized migrating joint tenderness
Correct Answer: D
Rationale: Generalized migrating joint tenderness (polyarthritis) is a hallmark symptom of rheumatic fever, reflecting the inflammatory process affecting multiple joints. An elevated ASO titer (not decreased) would indicate a recent streptococcal infection, and the other options are less specific.
The nurse would be correct to set the infusion pump for which hourly rate?
- A. 50 mL
- B. 75 mL
- C. 100 mL
- D. 125 mL
Correct Answer: D
Rationale: The order is 1,000 mL over 8 hours. Dividing 1,000 by 8 gives 125 mL/hour, the correct rate for the infusion pump.
Which statement by the client indicates that teaching has been effective?
- A. My partner should use a condom when lesions are present to prevent transmission.
- B. I should douche after intercourse to prevent becoming infected.
- C. I should apply acyclovir to lesions before intercourse to prevent transmission.
- D. I should avoid sexual contact, especially when lesions or symptoms are present.
Correct Answer: D
Rationale: Avoiding sexual contact when lesions or symptoms are present is the most effective way to prevent herpes transmission, indicating successful teaching.