Nokea
A mother is told that she should bottle feed her child for medical reasons. Which of the following maternal disease states are consistent with the recommendation? Select all that apply.
- A. Untreated
- B. active tuberculosis.
- C. Hepatitis B surface antigen positive.
- D. Human immunodeficiency virus positive.
Correct Answer: A
Rationale: Breastfeeding is contraindicated in untreated TB and HIV.
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A client's vital signs and reflexes were normal throughout pregnancy, labor, and delivery. Four hours after delivery the client's vitals are 98.6°F, P 72, R 20, BP 150/100, and her reflexes are 4+. She has an intravenous infusion running with 20 units of Pitocin (oxytocin) added. Which of the following actions by the nurse is appropriate?
- A. Nothing, because the results are normal.
- B. Notify the obstetrician of the findings.
- C. Discontinue the intravenous immediately.
- D. Reassess the client after fifteen minutes.
Correct Answer: B
Rationale: Elevated blood pressure requires medical evaluation.
A breastfeeding mother mentions to the nurse that she has heard that babies sleep better at night if they are given a small amount of rice cereal in the evening. Which of the following comments by the nurse is appropriate?
- A. That is correct. The rice cereal takes longer for them to digest so they sleep better and longer.
- B. It is recommended that babies receive only breast milk for the first 4 to 6 months of their lives.
- C. It is too early for rice cereal
- D. but I would recommend giving apple sauce at 3 months of age and apple juice 1 month later.
Correct Answer: B
Rationale: Exclusive breastfeeding is recommended for the first 6 months.
What percentage of weight loss did the baby experience? Calculate to the nearest hundredth.
- A. 5.55%
- B. 7.20%
- C. 6.85%
- D. 6.90%
Correct Answer: B
Rationale: Calculation: (3,278 - 3,042) / 3,278 * 100 = 7.20%
A client who has been diagnosed with deep vein thrombosis has been ordered to receive 12 units heparin/min. The nurse receives a 500-mL bag of D5W with 20,000 units of heparin added from the pharmacy. At what rate in mL/hr should the nurse set the infusion pump? (Calculate to the nearest whole.)
- A. 30
- B. NA
- C. NA
- D. NA
Correct Answer: A
Rationale: Calculation: 12 units × 500 mL ÷ 20,000 units = 30 mL/hr.
A new father calls the nurse’s station stating that his wife, who delivered last week, is happy one minute and crying the next. He states, “She was never like this before the baby was born.” How should the nurse best respond?
- A. Reassure him that this behavior is normal.
- B. Advise him to get immediate psychological help for her.
- C. Tell him to ignore the mood swings because they will go away.
- D. Instruct him in the signs, symptoms, and duration of postpartum blues.
Correct Answer: A
Rationale: The correct answer is A. The nurse should reassure the father that his wife's behavior of mood swings is normal after childbirth due to hormonal changes and adjustment to new responsibilities. This response validates the father's concerns, provides education on common postpartum experiences, and offers support.
Incorrect choices:
B: Immediate psychological help is not warranted for typical postpartum mood swings.
C: Ignoring the mood swings can lead to misunderstandings and lack of support for the mother.
D: Instructing on postpartum blues is more clinical and may not address the father's immediate concerns.