Nokea
A client who is pregnant and has phenylketonuria (PKU) is receiving teaching from a nurse. Which of the following foods should the nurse instruct the client to eliminate from her diet?
- A. Peanut butter
- B. Potatoes
- C. Apple juice
- D. Broccoli
Correct Answer: A
Rationale: The correct answer is A: Peanut butter. Phenylketonuria (PKU) is a metabolic disorder where the body can't process phenylalanine found in protein foods. Peanut butter is high in protein and contains phenylalanine, so it should be eliminated from the client's diet. Potatoes, apple juice, and broccoli are low in protein and do not contain high levels of phenylalanine, so they do not need to be eliminated. It is crucial for the client to avoid foods high in phenylalanine to prevent the buildup of toxic levels in the body, which can lead to serious health issues.
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A client is being discharged after childbirth. At 4 weeks postpartum, the client should contact the provider for which of the following client findings?
- A. Scant, non-odorous white vaginal discharge
- B. Uterine cramping during breastfeeding
- C. Sore nipple with cracks and fissures
- D. Decreased response with sexual activity
Correct Answer: C
Rationale: The correct answer is C: Sore nipple with cracks and fissures. This is indicative of possible breastfeeding issues like improper latch or infection, requiring prompt intervention to prevent complications. Scant, non-odorous white vaginal discharge (A) is normal postpartum lochia. Uterine cramping during breastfeeding (B) is common due to oxytocin release. Decreased response with sexual activity (D) is a common postpartum concern but not an urgent issue at 4 weeks. Addressing sore nipples promptly is crucial for successful breastfeeding and maternal well-being.
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.
A newborn is noted to have secretions bubbling out of the nose and mouth after delivery. What is the nurse's priority action?
- A. Suction the nose with a bulb syringe.
- B. Suction the mouth with a bulb syringe.
- C. Use a suction catheter with low negative pressure.
- D. Turn the newborn on their side.
Correct Answer: B
Rationale: The correct answer is B: Suction the mouth with a bulb syringe. This is the priority action because secretions in the mouth can obstruct the airway and lead to respiratory distress. Suctioning the mouth first helps clear the airway effectively. Suctioning the nose with a bulb syringe (choice A) may not address the immediate risk of airway obstruction. Using a suction catheter with low negative pressure (choice C) can be too strong for a newborn. Turning the newborn on their side (choice D) may not effectively address the airway obstruction from secretions in the mouth.
When checking for the Moro reflex in a newborn, what action should the nurse take?
- A. Hold the newborn vertically under arms and allow one foot to touch the table.
- B. Stimulate the pads of the newborn's hands with stroking or massage.
- C. Stimulate the soles of the newborn's feet on the outer lateral surface of each foot.
- D. Hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall backward.
Correct Answer: D
Rationale: The correct answer is D because the Moro reflex is elicited by sudden head movement or loud noise, causing the infant to extend their arms, then bring them back in a hugging motion. By holding the newborn in a semi-sitting position and allowing their head and trunk to fall backward, the nurse can observe the Moro reflex. Choices A, B, and C do not correctly elicit the Moro reflex as they involve different stimuli or movements that do not trigger the characteristic response of arm extension followed by flexion.
A client who is postpartum has a slightly boggy and displaced fundus to the right. Which of the following actions should the nurse take based on these findings?
- A. Encourage the client to perform Kegel exercises.
- B. Encourage the client to move to the left lateral position.
- C. Ask the client to rate her pain.
- D. Assist the client to the bathroom to void.
Correct Answer: D
Rationale: The correct answer is D: Assist the client to the bathroom to void. A boggy and displaced fundus to the right in a postpartum client suggests a full bladder, which can displace the uterus. Voiding helps the uterus contract back to its normal position, reducing the risk of postpartum hemorrhage. Encouraging Kegel exercises (A) is not appropriate in this situation. Moving to the left lateral position (B) may provide temporary relief but does not address the underlying issue. Asking the client to rate her pain (C) is not relevant to the management of a displaced fundus.