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: The correct answer is B: Assess the newborn's latch while breastfeeding. Sore nipples in breastfeeding can be caused by improper latch, leading to discomfort for the mother. By assessing the newborn's latch, the nurse can identify any issues such as shallow latch or poor positioning that may be causing the soreness. This allows for timely intervention to improve the latch, alleviate nipple soreness, and promote successful breastfeeding.
Choice A is incorrect as spacing out feedings can lead to engorgement and decreased milk supply.
Choice C is incorrect as limiting breastfeeding time can affect milk production and hinder proper milk transfer.
Choice D is incorrect as offering formula may interfere with breastfeeding establishment and can decrease milk supply.
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Which stage of labor is characterized by the delivery of the placenta?
- A. First stage
- B. Second stage
- C. Third stage
- D. Fourth stage
Correct Answer: C
Rationale: The correct answer is C: Third stage. This stage is characterized by the delivery of the placenta. It occurs after the baby is born (second stage) and involves the detachment and expulsion of the placenta from the uterus. The first stage is characterized by cervical dilation and effacement, while the fourth stage is the immediate postpartum period. The second stage is focused on the actual birth of the baby. Therefore, the delivery of the placenta specifically occurs in the third stage of labor.
Which of the following is a potential indication for a forceps-assisted delivery?
- A. Fetal distress
- B. Maternal hemorrhage
- C. Prolonged second stage of labor
- D. All of the above
Correct Answer: C
Rationale: A prolonged second stage of labor is a common indication for a forceps-assisted delivery.
A nurse is caring for a newborn immediately following birth. For which of the following reasons should the nurse delay the instillation of antibiotic ophthalmic ointment?
- A. To allow manifestations of infection to be identified
- B. The newborn weighs less than 2.5 kg (5.5 lb)
- C. The newborn was delivered via cesarean birth
- D. To facilitate bonding between the newborn and parent
Correct Answer: D
Rationale: The correct answer is D: To facilitate bonding between the newborn and parent. Delaying the instillation of antibiotic ointment allows for immediate skin-to-skin contact and bonding between the newborn and parent, promoting attachment and emotional connection. This is a crucial aspect of postnatal care and has long-term benefits for the newborn's emotional and psychological development. Choices A, B, and C are incorrect because delaying antibiotic ointment instillation for reasons such as identifying infection, low birth weight, or mode of delivery could potentially result in harm to the newborn by not providing immediate protection against eye infections, which can be serious and lead to vision impairment.
A nurse is caring for a client who is in active labor and notes the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia?
- A. Maternal hypoglycemia
- B. Chorioamnionitis
- C. Fetal anemia
- D. Maternal fever
Correct Answer: C
Rationale: Fetal anemia can lead to bradycardia due to reduced oxygen delivery to the fetal heart.
A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?
- A. Maintain the client NPO throughout the procedure.
- B. Place the client in a supine position.
- C. Instruct the client to massage the abdomen to stimulate fetal movement.
- D. Instruct the client to press the provided button each time fetal movement is detected.
Correct Answer: D
Rationale: Pressing the button each time fetal movement is detected helps monitor fetal well-being by correlating movement with heart rate accelerations, which is the purpose of a nonstress test.