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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After birth, the nurse immediately dries a neonate’s face and hair with a clean, prewarmed towel. After drying, the nurse covers the neonate’s hair with a cap. What type of heat loss is the nurse preventing?
- A. convection
- B. conduction
- C. evaporation
- D. radiation
Correct Answer: C
Rationale: Covering the neonate's head prevents heat loss through evaporation of moisture from the scalp.
What action by the nurse takes priority in safeguarding a neonates safety and well-being?
- A. Ensuring that the baby wears an abduction alarm
- B. Keeping the baby with the mother at all times
- C. Requiring visitors to the unit to wear identification
- D. Providing proper identification and constant surveillance
Correct Answer: A
Rationale: Careful and continuous monitoring of infants and proper identification per agency protocol is the best way to ensure a babys safety and well-being. Some institutions may use abduction alarms. Keeping the baby with the mother at all times may not always be possible. Proper identification of visitors is important
A neonate has difficulty maintaining a normal temperature. A student nurse prepares to place the infant under a radiant warmer. What action by the student leads the faculty member to intervene?
- A. Assesses the surrounding area for drafts
- B. Ensures the infant is dried off completely
- C. Observes the respiratory rate at the same time
- D. Wraps the baby in a warmed blanket
Correct Answer: D
Rationale: Radiant heater units warm only the outer surface of objects in them so it is counterproductive to dress the baby or cover the baby with blankets. The other actions are appropriate.
An infant was born with anencephaly and was taken immediately to the NICU. The parents are about to visit for the first time. What action by the nurse is most appropriate?
- A. Call the hospital chaplain to visit the parents.
- B. Obtain informed consent for emergency surgery.
- C. Prepare the parents for how the infant will look.
- D. Show the parents proper gowning and gloving.
Correct Answer: C
Rationale: Infants born with anencephaly (incomplete closure of the anterior portion of the neural tube) are often missing parts of the brain, forehead, skull, and occiput. The nurse must be very sensitive in working with the parents of such children and needs to prepare the parents for how the child will look. Well-prepared parents have a better chance of being able to bond with their child. A visit from the chaplain may or may not be welcomed. Emergency surgery is not performed. Proper gowning and gloving are not needed unless the infant is in isolation.
A faculty member explains to a nursing student that the best way to prevent hemorrhage from injuries in a neonate is which of the following?
- A. Administer vitamin K1 phytonadione (AquaMEPHYTON).
- B. Handle the infant carefully while wearing soft gloves.
- C. Keep the infant swaddled in several layers of blankets.
- D. Teach the parents how to trim the babys fingernails.
Correct Answer: A
Rationale: AquaMEPHYTON is given to newborns to promote normal blood clotting. The infants intestinal tract is sterile at birth and does not have the bacteria needed to create vitamin K