Nokea
A mother, who gave birth 5 minutes ago, states that she would like to breastfeed. The baby's Apgar score is 9/9. Which of the following actions should the nurse perform first?
- A. Assist the woman to breastfeed.
- B. Dress the baby in a shirt and diaper.
- C. Administer the ophthalmic prophylaxis.
- D. Take the baby's rectal temperature.
Correct Answer: A
Rationale: Early breastfeeding promotes bonding and colostrum intake.
You may also like to solve these questions
The nurse reviews postpartum discharge instructions regarding sexual health. What information is important to review?
- A. Place nothing in the vagina for 4–6 weeks.
- B. Pregnancy cannot occur until 3 months after birth.
- C. Sexual intercourse can resume after discharge from the facility.
- D. Postpartum persons do not have a need for sexual intimacy.
Correct Answer: A
Rationale: Rationale for Correct Answer (A):
- A: Correct because postpartum women should avoid placing anything in the vagina to prevent infection and allow healing.
- B: Incorrect because ovulation can occur before the first postpartum period.
- C: Incorrect because resuming sexual intercourse should be based on individual healing and comfort, not just discharge.
- D: Incorrect because sexual intimacy is a normal part of relationships and should be discussed postpartum for emotional well-being.
The nurse is providing discharge counseling to a woman who is breastfeeding her baby. What should the nurse advise the woman to do if she should palpate tender, hard nodules in her breasts?
- A. Gently massage the areas toward the nipple, especially during feedings.
- B. Apply ice to the areas between feedings.
- C. Bottle feed for the next twenty-four hours.
- D. Apply lanolin ointment to the areas after each and every breastfeeding.
Correct Answer: A
Rationale: Massaging helps resolve blocked ducts.
A client is 10 minutes postpartum from a forceps delivery of a 4,500-gram neonate with a cleft lip. The physician performed a right mediolateral episiotomy during the delivery. The client is at risk for each of the following nursing diagnoses. Which of the diagnoses is highest priority at this time?
- A. Ineffective breastfeeding.
- B. Fluid volume deficit.
- C. Infection.
- D. Pain.
Correct Answer: D
Rationale: Pain management is critical post-episiotomy.
A mother asks whether or not she should be concerned that her baby never opens his mouth to breathe when his nose is so small. Which of the following is the nurse's best response?
- A. The baby does rarely open his mouth but you can see that he isn't in any distress.
- B. Babies usually breathe in and out through their noses so they can feed without choking.
- C. Everything about babies is small. It truly is amazing how everything works so well.
- D. You are right. I will report the baby's small nasal openings to the pediatrician right away.
Correct Answer: B
Rationale: Nasal breathing is normal in newborns to allow simultaneous feeding and breathing.
A woman has just had a macrosomic baby after a 12-hour labor. For which of the following complications should the woman be carefully monitored?
- A. Uterine atony.
- B. Hypoprolactinemia.
- C. Infection.
- D. Mastitis.
Correct Answer: A
Rationale: Macrosomic deliveries increase atony risk.