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A client who is 2 days postpartum reports that their 4-year-old son, who was previously toilet trained, is now wetting himself frequently. Which of the following statements should the nurse provide to the client?
- A. Your son may not have been ready for toilet training and should wear training pants.
- B. Your son is displaying an adverse sibling response.
- C. Your son may benefit from counseling.
- D. Consider enrolling your son in preschool to address the behavior.
Correct Answer: B
Rationale: The correct answer is B: Your son is displaying an adverse sibling response. This is the correct answer because the 4-year-old's regression in toilet training is likely a response to the recent birth of a new sibling. This behavior is common as the older child may feel jealous or neglected, leading to regression. Providing this statement will help the client understand the underlying cause of the behavior and address it appropriately.
Incorrect choices:
A: This choice suggests the child was not ready for toilet training, which is not the primary issue here.
C: Counseling may be beneficial in some cases but is not the first-line intervention for this situation.
D: Enrolling in preschool may not directly address the underlying cause of the behavior, which is related to the new sibling.
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A client who is breastfeeding and has mastitis is receiving teaching from the nurse. Which of the following responses should the nurse make?
- A. Limit the amount of time the infant nurses on each breast.
- B. Nurse the infant only on the unaffected breast until resolved.
- C. Completely empty each breast at each feeding or use a pump.
- D. Wear a tight-fitting bra until lactation has ceased.
Correct Answer: C
Rationale: The correct answer is C: Completely empty each breast at each feeding or use a pump. This is the correct response because it helps to ensure effective milk removal, which is crucial for treating mastitis. By fully emptying the breast, the nurse can prevent milk stasis and promote healing.
A: Limiting the time the infant nurses on each breast may lead to incomplete milk removal, worsening the condition.
B: Nursing only on the unaffected breast does not address the issue of milk stasis in the affected breast and may lead to further complications.
D: Wearing a tight-fitting bra can exacerbate mastitis by restricting milk flow and increasing discomfort.
A client is exhibiting tearfulness, insomnia, lack of appetite, and a feeling of letdown after childbirth. Which of the following conditions is associated with these manifestations?
- A. Postpartum fatigue
- B. Postpartum psychosis
- C. Letting-go phase
- D. Postpartum blues
Correct Answer: D
Rationale: The correct answer is D: Postpartum blues. This temporary condition occurs in the first few days after childbirth and is characterized by symptoms like tearfulness, insomnia, lack of appetite, and feeling letdown. Here's the rationale:
1. Postpartum blues are common and typically resolve within a few days to a week postpartum.
2. The symptoms mentioned align with the typical presentation of postpartum blues, which includes mood swings, irritability, and crying spells.
3. Postpartum fatigue (choice A) is a general symptom post-childbirth but does not specifically encompass the emotional and psychological symptoms described.
4. Postpartum psychosis (choice B) is a severe condition characterized by hallucinations, delusions, and disorganized thinking, which are not present in the client's presentation.
5. Letting-go phase (choice C) refers to the process of detachment from the pregnancy and accepting the reality of the newborn, but it does not encompass the specific symptoms described in
During an assessment, a healthcare provider observes small pearly white nodules on the roof of a newborn's mouth. This finding is a characteristic of which of the following conditions?
- A. Mongolian spots
- B. Milia spots
- C. Erythema toxicum
- D. Epstein's pearls
Correct Answer: D
Rationale: The correct answer is D: Epstein's pearls. These small pearly white nodules are commonly found on the roof of newborns' mouths and are considered a normal finding. They are formed from trapped epithelial cells during the development of the baby's mouth. They are harmless and typically resolve on their own without treatment.
A: Mongolian spots are bluish-black or bruise-like markings found on the skin, not in the mouth.
B: Milia spots are small, white, raised bumps on the skin, not found in the mouth.
C: Erythema toxicum is a common benign rash in newborns, not related to the mouth.
In summary, Epstein's pearls are the correct answer due to their specific location in the newborn's mouth, their appearance, and the fact that they are a normal finding in newborns. The other choices are incorrect as they describe different conditions not related to the oral cavity.
While assisting with the care of an infant with a high bilirubin level receiving phototherapy, which finding should the nurse prioritize for reporting to the charge nurse?
- A. Conjunctivitis
- B. Bronze skin discoloration
- C. Sunken fontanels
- D. Maculopapular skin rash
Correct Answer: C
Rationale: The correct answer is C: Sunken fontanels. This finding indicates dehydration in the infant, which can be a serious complication requiring immediate intervention. Dehydration can lead to further elevation of bilirubin levels and potential neurological complications. Reporting this to the charge nurse is crucial for prompt assessment and intervention.
Incorrect choices:
A: Conjunctivitis - Although important, it is not a priority over a sign of dehydration.
B: Bronze skin discoloration - This may be a common side effect of phototherapy and does not indicate an urgent issue.
D: Maculopapular skin rash - While it should be monitored, it does not take precedence over a sign of dehydration.
A nurse concludes that the parent of a newborn is not showing positive indications of parent-infant bonding. The parent appears very anxious and nervous when asked to bring the newborn to the other parent. Which of the following actions should the nurse use to promote parent-infant bonding?
- A. Hand the parent the newborn and suggest that they change the diaper.
- B. Ask the parent why they are so anxious and nervous.
- C. Tell the parent that they will grow accustomed to the newborn.
- D. Provide reinforcement about infant care when the parent is present.
Correct Answer: D
Rationale: The correct answer is D because providing reinforcement about infant care when the parent is present can help build the parent's confidence and competence in caring for the newborn, which can enhance parent-infant bonding. By offering support and guidance during interactions with the newborn, the parent can feel more comfortable and connected to the baby.
A: Handing the parent the newborn and suggesting they change the diaper may increase their anxiety and not address the underlying issue of bonding.
B: Asking the parent why they are anxious and nervous is important but may not directly promote bonding without providing concrete support.
C: Telling the parent they will grow accustomed to the newborn does not actively support bonding or address the parent's current concerns.
In summary, choice D is the best option as it provides practical assistance and positive reinforcement to help the parent feel more confident in caring for the newborn, ultimately fostering parent-infant bonding.