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A client delivered 2 days ago and has been given instructions on breast care for bottle-feeding mothers. Which of the following statements indicates that the nurse should reinforce the instructions to the client?
- A. I will wear a sports bra or a well fitting bra for several days.
- B. When showering, I'll direct water onto my shoulders.
- C. I will only use only water to clean my nipples.
- D. I will use a breast pump to remove any milk that may appear.
Correct Answer: D
Rationale: Using a breast pump can stimulate milk production, which is counterproductive for bottle-feeding mothers.
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A client asks about the side effects of oral contraceptives. Which of the following would the nurse include in the response?
- A. Weight loss is a common side effect.
- B. Nausea and breast tenderness may occur initially.
- C. Hair loss is frequently reported.
- D. Oral contraceptives decrease the risk of breast cancer.
Correct Answer: B
Rationale: Nausea and breast tenderness are common initial side effects of oral contraceptives, which often subside. Weight gain, not loss, may occur, hair loss is not typical, and oral contraceptives do not significantly reduce breast cancer risk.
When teaching a primiparous client about the growth and development of the neonate, which of the following should the nurse include as the usual age at which most babies are able to drink from a cup independently?
- A. 5 to 7 months.
- B. 8 to 10 months.
- C. 12 to 14 months.
- D. 15 to 16 months.
Correct Answer: C
Rationale: Most babies can drink from a cup independently by 12-14 months as motor skills develop.
After a vaginal delivery of a term neonate, the nurse observes that the neonate has one artery and one vein in the umbilical cord. The nurse notifies the pediatrician based on the analysis that this may be indicative of ?
- A. Respiratory anomalies.
- B. Musculoskeletal anomalies.
- C. Cardiovascular anomalies.
- D. Facial anomalies.
Correct Answer: C
Rationale: A single umbilical artery is associated with an increased risk of cardiovascular anomalies, warranting further evaluation.
During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she is aware of a "let-down sensation" in her breasts and asks what causes it. The nurse explains that the let-down sensation is stimulated by which of the following?
- A. Adrenalin.
- B. Estrogen.
- C. Prolactin.
- D. Oxytocin.
Correct Answer: D
Rationale: Oxytocin triggers the let-down reflex, releasing milk during breastfeeding.
The nurse is planning care for a multigravid client hospitalized at 36 weeks' gestation with confirmed rupture of membranes and no evidence of labor. Which of the following would the nurse expect the physician to order?
- A. Frequent assessments of cervical dilation.
- B. Intravenous oxytocin administration.
- C. Vaginal culture for Neisseria gonorrhoeae.
- D. Sonogram for amniotic fluid volume index.
Correct Answer: C
Rationale: Vaginal cultures help identify infections after membrane rupture.