Nokea
A nurse is assisting a postpartum person with breastfeeding. What is the most important factor for successful breastfeeding?
- A. frequent breastfeeding
- B. proper latch
- C. positioning
- D. administer oxytocin
Correct Answer: B
Rationale: The correct answer is B: proper latch. A proper latch is crucial for successful breastfeeding as it ensures the baby is effectively extracting milk from the breast, preventing nipple soreness and ensuring an adequate milk supply. Without a proper latch, the baby may not receive enough milk, leading to issues such as poor weight gain and frustration for both the baby and the person breastfeeding. Frequent breastfeeding (choice A) is important, but without a proper latch, it may not be effective. Positioning (choice C) is also important, but proper latch takes precedence. Administering oxytocin (choice D) is not necessary for successful breastfeeding and may have side effects.
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A 36-week gestation gravid client is complaining of dyspnea when lying flat.
- A. Maternal hypertension.
- B. Fundal height.
- C. Hydramnios.
- D. Congestive heart failure.
Correct Answer: B
Rationale: As the uterus grows, the fundal height increases, which can press on the diaphragm and lead to shortness of breath when lying flat.
A nurse is assessing a postpartum person for signs of infection. What is the most concerning finding in the first 24 hours after delivery?
- A. Fever
- B. Redness and swelling at the site
- C. Increased heart rate
- D. Fatigue
Correct Answer: A
Rationale: The correct answer is A: Fever. In the first 24 hours postpartum, fever is the most concerning finding as it can indicate infection, such as endometritis or mastitis. Fever is a common early sign of infection and requires immediate assessment and intervention. Redness and swelling at the site (B) could be normal postpartum findings. Increased heart rate (C) may be a nonspecific response to stress or dehydration. Fatigue (D) is common postpartum but not typically indicative of infection in the first 24 hours. Fever warrants prompt attention due to the risk of serious complications if left untreated.
A nurse is caring for a pregnant patient who is at 26 weeks gestation and reports a sudden decrease in fetal movement. Which action should the nurse take first?
- A. Encourage the patient to drink a sugary beverage and count fetal movements.
- B. Monitor the patient's blood pressure and assess for any signs of hypertension.
- C. Perform a nonstress test to assess fetal well-being.
- D. Call the healthcare provider immediately to report the decrease in fetal movement.
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to drink a sugary beverage and count fetal movements. This action is appropriate as decreased fetal movement can indicate fetal distress, and the sugary beverage can stimulate the baby to move. If the baby responds with increased movements, it indicates a reassuring fetal status. If there is no improvement, further evaluation can be pursued.
Incorrect choices:
B: Monitoring blood pressure is not the priority in this situation as the main concern is fetal movement.
C: Performing a nonstress test is not the first action to take as it requires time and resources, which may delay immediate intervention.
D: While eventually contacting the healthcare provider is important, the immediate action should be to assess fetal well-being by encouraging fetal movements.
A client asks the nurse, “Could you explain how the baby’s blood and my blood separate at delivery?” Which of the following responses is appropriate for the nurse to make?
- A. When the placenta is born, the circulatory systems separate.
- B. When the doctor clamps the cord, the blood stops mixing.
- C. The separation happens after the baby takes the first breath. The baby’s oxygen no longer has to come from you.
- D. The blood actually never mixes. Your blood supply and the baby’s blood supply are completely separate.
Correct Answer: D
Rationale: During pregnancy, the mother's and baby's blood supplies do not mix. The placenta acts as a barrier and facilitates the exchange of nutrients, gases, and waste products between the maternal and fetal bloodstreams without direct mixing. This ensures that each individual maintains their own circulatory system.
The nurse is caring for a pregnant patient who is 38 weeks gestation and reports feeling pelvic pressure and mild cramping. What should the nurse do first?
- A. Monitor the fetal heart rate and check for signs of labor.
- B. Instruct the patient to rest and monitor the symptoms.
- C. Assess the patient's blood pressure and urine for protein.
- D. Perform a pelvic exam to assess for cervical dilation.
Correct Answer: A
Rationale: The correct answer is A because monitoring the fetal heart rate and checking for signs of labor are essential in assessing the well-being of the fetus and determining if the patient is in active labor. This step helps the nurse identify any potential complications and take appropriate actions promptly.
Choice B is incorrect because simply instructing the patient to rest may not address the underlying cause of pelvic pressure and cramping.
Choice C is incorrect as assessing blood pressure and urine for protein is not the priority in this situation.
Choice D is incorrect because performing a pelvic exam should be done after monitoring fetal well-being and ruling out active labor.