Nokea
A neonate is in the active alert behavioral state. Which of the following would the nurse expect to see?
- A. Baby is showing signs of hunger and frustration.
- B. Baby is starting to whimper and cry.
- C. Baby is wide awake and attending to a picture.
- D. Baby is asleep and breathing rhythmically.
Correct Answer: C
Rationale: Active alert state is characterized by wakefulness and attentiveness.
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On admission to the labor and delivery suite, the nurse assesses the discharge needs of a primipara who will be discharged home 4 days after a cesarean delivery. Which of the following questions should the nurse ask the client?
- A. Have you ever had anesthesia before?
- B. Do you have any allergies?
- C. Do you scar easily?
- D. Are there many stairs in your home?
Correct Answer: D
Rationale: Home environment impacts recovery.
Which of the following actions would encourage the baby to open the mouth wide for feeding?
- A. Holding the baby in the en face position.
- B. Pushing down on the baby's lower jaw.
- C. Tickling the baby's lips with the nipple.
- D. Giving the baby a trial bottle of formula.
Correct Answer: C
Rationale: Tickling the lips stimulates rooting reflex.
Four pregnant women advise the nurse that they wish to breastfeed their babies. Which of the mothers should be advised to bottle feed her child?
- A. The woman with a neoplasm requiring chemotherapy.
- B. The woman with cholecystitis requiring surgery.
- C. The woman with a concussion.
- D. The woman with thrombosis.
Correct Answer: A
Rationale: Chemotherapy agents can harm the baby through breast milk.
The nurse is planning comfort measures to implement for a patient after a vaginal birth. Which measures should the nurse plan to include in the patient’s care plan? (Select all that apply.)
- A. Sitz baths four times a day
- B. Use of only warm water with the sitz baths
- C. Topical anesthetic spray after perineal care
- D. Ice pack to the perineum for the first 24 hours
Correct Answer: A
Rationale: The correct answer is A: Sitz baths four times a day. Sitz baths promote healing, reduce swelling, and provide comfort after a vaginal birth. Warm water helps to soothe the perineal area. Choices B, C, and D are incorrect because using warm water alone may not be as effective as sitz baths, topical anesthetic spray may not be necessary for routine care, and ice packs may not be recommended for the first 24 hours due to the risk of vasoconstriction and decreased blood flow to the area.
A client who is post-cesarean section for severe preeclampsia is receiving magnesium sulfate via IV pump and morphine sulfate via patient-controlled anesthesia (PCA) pump. The nurse enters the room on rounds and notes that the client is not breathing. Which of the following actions should the nurse perform first?
- A. Give two breaths.
- B. Discontinue medications.
- C. Call a code.
- D. Check carotid pulse.
Correct Answer: A
Rationale: Immediate ventilation is critical.