Nokea
A nurse is caring for a client who is 1 day postpartum and breastfeeding her newborn. The client reports sore nipples. Which of the following actions should the nurse take?
- A. Instruct the client to wait 4 hr between daytime feedings.
- B. Assess the newborn's latch while breastfeeding.
- C. Have the client limit the length of breastfeeding to 5 min per breast.
- D. Offer supplemental formula between the newborn's feedings.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Assessing the newborn's latch while breastfeeding is crucial in addressing sore nipples. A poor latch can lead to nipple pain. By ensuring proper latch, the nurse can help alleviate the client's discomfort. Other actions are incorrect:
A: Waiting 4 hr between feedings can lead to engorgement and worsen nipple soreness.
C: Limiting breastfeeding time to 5 min can hinder milk supply and not address the root cause.
D: Offering supplemental formula can interfere with establishing breastfeeding and may not address the latch issue.
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A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?
- A. O2 saturation
- B. Temperature
- C. Blood pressure
- D. Urinary output
Correct Answer: B
Rationale: The correct answer is B: Temperature. During an amniotomy, there is an increased risk of infection due to the introduction of bacteria into the uterine cavity. Monitoring the client's temperature is crucial to detect any signs of infection promptly. A sudden spike in temperature could indicate chorioamnionitis, a serious infection that can harm both the mother and the baby. O2 saturation (A), blood pressure (C), and urinary output (D) are important assessments but are not the priority in this situation. Monitoring O2 saturation is essential for fetal well-being but is not directly related to the amniotomy procedure. Blood pressure monitoring is significant for detecting any changes in maternal status, but infection assessment takes precedence in this case. Urinary output is essential for assessing hydration status and kidney function, but infection monitoring is more critical during an amniotomy.
Which of the following conditions should the nurse identify as being consistent with the adolescent's assessment findings? For each finding click to specify if the assessment findings are consistent with trichomoniasis, gonorrhea, or candidiasis. Each finding may support more than one disease process.
- A. Abdominal pain.
- B. Greenish discharge.
- C. Diabetes.
- D. Pain on urination.
- E. Absence of condom.
Correct Answer: B, D
Rationale: Sure, here is the detailed explanation:
- Trichomoniasis: Trichomoniasis typically presents with greenish discharge but not pain on urination.
- Gonorrhea: Gonorrhea can cause both greenish discharge and pain on urination.
- Candidiasis: Candidiasis does not typically present with greenish discharge or pain on urination.
Therefore, based on the assessment findings provided:
- Abdominal pain: Not specific to any of the given conditions.
- Greenish discharge: Consistent with both gonorrhea and trichomoniasis.
- Diabetes: Not directly related to the symptoms provided.
- Pain on urination: Consistent with gonorrhea.
- Absence of condom: Not relevant to the symptoms provided.
The correct answer is B, D as greenish discharge and pain on urination are consistent with both gonorrhea and trichomoniasis, making them the most likely conditions based on the assessment findings.
A nurse is admitting a client to the birthing unit who reports her contractions started 1 hr ago. The nurse determines the client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions?
- A. Ectopic pregnancy
- B. Hyperemesis gravidarum
- C. Incompetent cervix
- D. Postpartum hemorrhage
Correct Answer: D
Rationale: The correct answer is D: Postpartum hemorrhage. The client being 80% effaced and 8 cm dilated indicates she is in active labor, not at risk for ectopic pregnancy (A). Hyperemesis gravidarum (B) is severe nausea and vomiting during pregnancy, unrelated to cervical dilation. Incompetent cervix (C) is characterized by painless cervical dilation in the second trimester. Postpartum hemorrhage (D) is a risk due to the advanced cervical dilation and effacement, making it more likely for excessive bleeding during and after delivery.
A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect?
- A. Decreased platelet count
- B. Increased erythrocyte sedimentation rate (ESR)
- C. Decreased megakaryocytes
- D. Increased WBC
Correct Answer: A
Rationale: The correct answer is A: Decreased platelet count. In ITP, there is a decrease in the number of platelets, leading to an increased risk of bleeding. Platelets are essential for blood clotting, so a decreased count can result in easy bruising, petechiae, and prolonged bleeding. The other choices are incorrect because in ITP, there is no significant increase in ESR, decrease in megakaryocytes (which are platelet precursors), or increase in WBC count. By understanding the pathophysiology of ITP and its effects on platelets, we can confidently select choice A as the expected finding in this scenario.
A nurse is assessing a newborn whose mother had gestational diabetes mellitus. The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?
- A. Abdominal distention
- B. Petechiae
- C. Increased muscle tone
- D. Jitteriness
Correct Answer: D
Rationale: The correct answer is D: Jitteriness. In newborns of mothers with gestational diabetes, they are at risk for hypoglycemia due to the sudden drop in glucose levels after birth. Jitteriness is a common manifestation of hypoglycemia in newborns, indicating neurological impairment. Abdominal distention (A) is not typically associated with hypoglycemia. Petechiae (B) are tiny red or purple spots on the skin and are not specific to hypoglycemia. Increased muscle tone (C) is more commonly seen in conditions like cerebral palsy. Jitteriness (D) is a typical sign of hypoglycemia in newborns and requires prompt attention to prevent further complications.