Nokea
A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective to prevent nipple soreness?
- A. Wear a cotton bra
- B. Increase nursing time gradually
- C. Correctly place the infant on the breast
- D. Manually express a small amount of milk before nursing
Correct Answer: C
Rationale: The most common cause of nipple soreness is incorrect positioning (C) of the infant on the breast, e.g., grasping too little of the areola or grasping on the nipple.
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Following the vaginal delivery of a large-for-gestation-age (LGA) infant a woman is admitted to the intensive care unit due to postpartum hemorrhaging. The client's medical record lists the client's religion as Jehovah's Witness. What action should the nurse take?
- A. Prepare to infuse multiple units of fresh frozen plasma
- B. Inform the client of the critical need for a blood transfusion
- C. Clarify the clients wishes about receiving blood products
- D. Obtain consent from the family to infuse packed red blood cells
Correct Answer: C
Rationale: Clarifying the client's wishes regarding blood products (C) respects her religious beliefs.
The nurse is assessing a patient's use of complementary and alternative therapies. Which should the nurse document as an alternative or complementary therapy practice?
- A. Practicing yoga daily
- B. Drinking green tea in the morning
- C. Taking omeprazole (Prilosec) once a day
- D. Using aromatherapy during a relaxing bath
Correct Answer: C
Rationale: Yoga, green tea, and aromatherapy are examples of complementary and alternative therapies.
A multigravida client arrives at the labor and delivery unit and tells the nurse that her bag of water has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the fetal heart rate is between 140 to 150 beats/minute. What action should the nurse implement next?
- A. Complete a sterile vaginal exam
- B. Take maternal temperature every 2 hours
- C. Prepare for an immediate cesarean birth
- D. Obtain sterile suction equipment
Correct Answer: A
Rationale: A vaginal exam (A) should be performed after the rupture of membranes to determine the presence of a prolapsed cord.
To determine cultural influences on a patient's diet, what is the nurse's primary action?
- A. Evaluate the patient's weight gain during pregnancy.
- B. Assess the socioeconomic status of the patient.
- C. Discuss the four food groups with the patient.
- D. Identify the food preferences and methods of food preparation common to the patient's culture.
Correct Answer: D
Rationale: The correct answer is D because identifying the food preferences and methods of food preparation common to the patient's culture is crucial in understanding cultural influences on their diet. This step helps the nurse tailor dietary recommendations that align with the patient's cultural background and preferences, promoting better adherence and health outcomes.
Option A is incorrect as weight gain during pregnancy is not directly related to cultural influences on diet. Option B, assessing socioeconomic status, is important but not the primary action for understanding cultural influences on diet. Option C, discussing the four food groups, is too generic and does not specifically address cultural influences on diet.
A client at 39-weeks gestation is admitted to the labor and delivery unit in active labor. The client's cervix is dilated 6 cm, 90% effaced, and the fetus is at 0 station. The client's membranes rupture spontaneously, and the fluid is clear. What action should the nurse take next?
- A. Monitor the fetal heart rate pattern.
- B. Perform a vaginal examination.
- C. Encourage the client to ambulate.
- D. Administer pain medication.
Correct Answer: A
Rationale: Monitoring the fetal heart rate pattern after membrane rupture is essential to detect any changes in fetal status.