Nokea
A new breast-feeding mother experiencing breast engorgement is provided with instructions regarding care for the condition. Which statement by the mother indicates to the nurse that she possesses an understanding of the measures that will provide comfort for the engorgement?
- A. I will breast-feed using only one breast.
- B. I will apply cold compresses to my breasts.
- C. I will avoid the use of a bra while my breasts are engorged.
- D. I will massage my breasts before feeding to stimulate letdown.
Correct Answer: D
Rationale: Comfort measures for breast engorgement include massaging the breasts before feeding to stimulate letdown, alternating the breasts during feeding, taking a warm shower or applying warm compresses just before feeding, and wearing a supportive well-fitting bra at all times. None of the other options suggest correct measures.
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The nurse is caring for a client with a history of breast cancer who is receiving chemotherapy. Which of the following laboratory values should the nurse monitor closely?
- A. White blood cell count.
- B. Blood glucose levels.
- C. Serum potassium.
- D. Hemoglobin A1c.
Correct Answer: A
Rationale: Chemotherapy can cause bone marrow suppression, requiring close monitoring of white blood cell counts for infection risk.
The mother of a 3-year-old child tells the nurse her child is 'fussy' and not as 'easy going' as her other children. She is having difficulty feeding the child because he fusses and cries when she serves a meal. The nurse should instruct the mother to:
- A. Allow the child to determine when feeding should occur.
- B. Not to feed the child if he cries.
- C. Provide structured feeding times and routines.
- D. Give the child finger foods and let him eat when he wants.
Correct Answer: C
Rationale: Structured feeding times and routines help establish consistent eating habits, reducing fussiness by providing predictability for the child.
A normal, healthy infant is brought to the clinic for the first immunization against polio. The nurse should administer this vaccine by what route?
- A. Oral route.
- B. I.M. route.
- C. Subcutaneous route.
- D. Intradermal route.
Correct Answer: A
Rationale: The polio vaccine for infants is administered orally (OPV) in many regions, though inactivated polio vaccine (IPV) is given intramuscularly in some settings. Based on the options, oral is correct.
A client has a prescription to have a set of arterial blood gases (ABGs) drawn, and the intended site is the radial artery. The nurse ensures that which is positive before the ABGs are drawn?
- A. Allen test
- B. Turner's sign
- C. Babinski reflex
- D. Brudzinski's sign
Correct Answer: A
Rationale: The Allen test is performed before drawing ABGs. Both the radial and ulnar arteries are occluded and then pressure on the ulnar artery is released. Observation is made in the distal circulation. If the results are positive, then the client has adequate circulation and the radial artery may be used. Turner's sign is the bluish discoloration of the flanks and is indicative of pancreatitis. The Babinski reflex is checked by stroking upward on the sole of the foot. Brudzinski's sign tests for nuchal rigidity by bending the head down toward the chest.
A family has taken home their newborn and later received a call from the pediatrician that the PKU levels for their newborn daughter are abnormally high. Additional testing confirmed the diagnosis of phenylketonuria. The parents refuse to believe the results as no one else in their family has the disease. The nurse explains that the disease:
- A. Is carried on recessive genes contributed by each parent.
- B. Is caused by a recessive gene contributed by either parent.
- C. Is cured by eliminating dietary protein for this child.
- D. Will not impact future childbearing for the family.
Correct Answer: A
Rationale: Phenylketonuria is an autosomal recessive disorder, requiring both parents to contribute a defective gene. It is not caused by a single parent's gene, cannot be cured by diet alone (though managed by low-phenylalanine diet), and may impact future childbearing as parents are carriers.