Nokea
A new mother is crying in her room. She tells the nurse that her new baby boy has enlarged breasts and she thinks that there is something wrong. How should the nurse respond?
- A. Enlarged breasts are common for both boys and girls. It will go away.
- B. Let me look at the baby for you.
- C. Everything is going to be just fine. Your baby is healthy.
- D. You should ask your doctor about that.
Correct Answer: A
Rationale: The correct answer is A. Enlarged breasts in newborn boys and girls are a common physiological phenomenon called breast engorgement due to maternal hormones. The nurse should reassure the mother that it is normal and will resolve on its own. Choice B is unnecessary as the nurse already knows the cause. Choice C is vague and does not address the mother's concern directly. Choice D is not ideal as the nurse can provide basic information on the issue.
You may also like to solve these questions
A breastfeeding mother complains of cramping. Which is the main cause of the client's afterpains?
- A. Infection of the suture line
- B. Constipation and bloating
- C. Contractions of the uterus
- D. Trauma during delivery
Correct Answer: C
Rationale: The correct answer is C: Contractions of the uterus. After giving birth, the uterus continues to contract to reduce in size, which can cause cramping or afterpains. This is a normal process known as involution. Infection of the suture line (A) would present with other symptoms like redness, swelling, and warmth. Constipation and bloating (B) may cause discomfort but are not directly related to afterpains. Trauma during delivery (D) could lead to pain but is not the main cause of afterpains in a breastfeeding mother.
A nurse is caring for a 3-year-old child with strabismus. Which of the following actions should the nurse advise the parents to implement to help prevent amblyopia?
- A. Wear corrective biconcave lenses.
- B. Prevent trauma to the eyes.
- C. Patch the strong eye.
- D. Instill artificial tears.
Correct Answer: C
Rationale: The correct answer is C: Patch the strong eye. Patching the strong eye helps improve vision in the weaker eye, which is essential in preventing amblyopia. By covering the strong eye, the brain is forced to rely on the weaker eye, strengthening its visual acuity. Wearing corrective biconcave lenses may help with refractive errors but does not directly address amblyopia prevention. Preventing trauma to the eyes is important for overall eye health but does not specifically target amblyopia prevention. Instilling artificial tears is used for dry eye syndrome and does not play a role in preventing amblyopia.
A nurse is caring for an infant with a history of vomiting due to gastroenteritis. Which of the following nursing interventions is considered the priority?
- A. Place the infant in a side or semi-reclined position.
- B. Administer oral rehydration and electrolyte therapy.
- C. Administer antiemetic medications as prescribed.
- D. Maintain a high-carbohydrate intake to prevent ketosis.
Correct Answer: A
Rationale: Positioning the infant prevents aspiration, which is the highest priority.
During the active phase of labor, the membranes rupture and the nurse notes green amniotic fluid. Which nursing action should be initiated immediately?
- A. Call the physician.
- B. Replace the soiled underpad.
- C. Test the fluid with pH (Nitrazine) paper.
- D. Assess fetal heart rate.
Correct Answer: D
Rationale: The correct answer is D: Assess fetal heart rate. This is important because green amniotic fluid indicates meconium staining, which can be a sign of fetal distress. Assessing the fetal heart rate immediately will help determine the baby's well-being. Calling the physician (choice A) may be necessary but assessing the fetal heart rate should be the priority. Replacing the underpad (choice B) can wait until after assessing the fetal heart rate. Testing the fluid with pH paper (choice C) may confirm the presence of meconium but assessing the fetal heart rate is more urgent.
A nurse provided discharge teaching to new parents on how to care for their newborn following circumcision. Which of the following statements by the parents indicates the need for further clarification?
- A. I should not remove the yellow exudate on the end of the penis.
- B. I will clean his penis with each diaper change.
- C. The circumcision will heal completely within a couple of weeks.
- D. I can give him a tub bath in two days.
Correct Answer: D
Rationale: The correct answer is D: "I can give him a tub bath in two days." This statement indicates the need for further clarification because newborns who have undergone circumcision should avoid submerging the area in water until it is fully healed to prevent infection. Tub baths should be avoided until the circumcision site has completely healed, which usually takes about 7-10 days. It is important to keep the area clean and dry during this time to promote healing.
Explanation for other choices:
A: "I should not remove the yellow exudate on the end of the penis." - Correct, as it is normal and part of the healing process.
B: "I will clean his penis with each diaper change." - Correct, as keeping the area clean helps prevent infection.
C: "The circumcision will heal completely within a couple of weeks." - Correct, as the healing process typically takes around 1-2 weeks.