Nokea
A newly delivered primiparous client asks the nurse, "Can my baby see?" Which of the following statements about neonatal vision should the nurse include in the explanation?
- A. Neonates primarily focus on moving objects.
- B. They can see objects up to 12 inches away.
- C. Usually they see clearly by about 2 days after birth.
- D. Neonates primarily distinguish light from dark.
Correct Answer: B
Rationale: Neonates can focus on objects about 8-12 inches away, which is optimal for bonding during feeding.
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A client is considering a hormonal IUD. Which of the following benefits should the nurse highlight?
- A. It provides protection against STIs.
- B. It can reduce menstrual bleeding over time.
- C. It requires replacement every year.
- D. It is suitable for women with heavy menstrual bleeding.
Correct Answer: B
Rationale: A hormonal IUD, like Mirena, can reduce menstrual bleeding over time, often leading to lighter periods or amenorrhea. It does not protect against STIs, lasts 3-7 years depending on the type, and is suitable for heavy bleeding, but B is the primary benefit.
The client is breast-feeding and asks the nurse about nutrition and diet. Which of the following statements by the client indicate understanding of dietary needs to promote successful breastfeeding? Select all that apply.
- A. I need to increase the number of meals I eat from three to five each day.
- B. I have to add about 500 more calories to my diet while I breast-feed.
- C. I need at least two servings of protein, like meat or eggs, with each meal.
- D. I need to double my fluids from my normal three to six glasses each day.
- E. I can eat more cheese and drink orange juice with calcium to increase my calcium intake.
Correct Answer: B,E
Rationale: An additional 500 calories and increased calcium intake are correct for breastfeeding; the other statements are inaccurate or excessive.
A woman who has delivered a healthy newborn is being discharged. As a part of the discharge teaching, the nurse should instruct the client to observe vaginal discharge for postpartum hemorrhage and notify the healthcare provider about?
- A. Bleeding that becomes lighter each day.
- B. Clots the size of golf balls.
- C. Saturating a pad in an hour.
- D. Lochia that last longer than 1 week.
Correct Answer: C
Rationale: Saturating a pad in an hour indicates excessive bleeding.
A multigravid client in active labor at term is diagnosed with polyhydramnios. The physician has instructed the client about possible neonatal complications related to the polyhydramnios. The nurse determines that the client has understood the instructions when the client states that polyhydramnios is associated with which of the following in the fetus or neonate?
- A. Renal dysfunction.
- B. Intrauterine growth retardation.
- C. Pulmonary hypoplasia.
- D. Gastrointestinal disorders.
Correct Answer: D
Rationale: Polyhydramnios is associated with fetal gastrointestinal disorders (e.g., esophageal atresia) that impair amniotic fluid absorption. Renal dysfunction, growth retardation, or pulmonary hypoplasia are more linked to oligohydramnios.
The cervix of a 15-year-old primigravid client admitted to the labor area is 2 cm dilated and 50% effaced. Her membranes are intact, and contractions are occurring every 5 to 6 minutes. Which of the following should the nurse recommend at this time?
- A. Resting in the right lateral recumbent position.
- B. Using in the left lateral recumbent position.
- C. Walking around in the hallway.
- D. Sitting in a comfortable chair for a period of time.
Correct Answer: C
Rationale: In early labor (2 cm dilation), ambulation (walking) promotes labor progression by using gravity to encourage fetal descent and enhance contractions. Lateral positions are better for rest or later stages, and sitting may not aid progression as effectively.