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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 mothers are often caused by improper latch. By assessing the newborn's latch, the nurse can identify any issues and provide guidance to the client on how to improve latch technique, which can alleviate nipple soreness. Waiting 4 hours between feedings (choice A) can lead to engorgement and decreased milk supply. Limiting breastfeeding time to 5 min per breast (choice C) can also affect milk supply. Offering supplemental formula (choice D) can interfere with establishing successful breastfeeding.
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A nurse is providing teaching to the parents of a newborn about the Plastibell circumcision technique. Which of the following information should the nurse include?
- A. The Plastibell will be removed 4 hours after the procedure.
- B. Make sure the newborn’s diaper is snug.
- C. Yellow exudate will form at the surgical site in 24 hours.
- D. Notify the provider if the end of your baby’s penis appears dark red.
Correct Answer: D
Rationale: The correct answer is D: Notify the provider if the end of your baby’s penis appears dark red. This is important to monitor for signs of infection, such as redness, swelling, or discharge. Yellow exudate forming in 24 hours (C) is incorrect as it may indicate infection. The Plastibell is typically removed after a few days, not 4 hours (A). Ensuring a snug diaper (B) is irrelevant to the circumcision technique.
A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?
- A. Administer broad-spectrum antibiotics.
- B. Monitor the rectal temperature every 4 hr.
- C. Cleanse the site with povidone-iodine.
- D. Prepare for surgical closure after 72 hr.
Correct Answer: A
Rationale: The correct answer is A: Administer broad-spectrum antibiotics. The leaking cerebrospinal fluid puts the newborn at risk for infection, so administering antibiotics helps prevent infection. Monitoring rectal temperature (B) is not directly related to preventing infection. Cleansing the site with povidone-iodine (C) may not be effective in preventing infection. Preparing for surgical closure after 72 hr (D) is important but addressing the risk of infection with antibiotics is the immediate priority.
A nurse is teaching about home safety with a client who is 2 days postpartum. Which of the following instructions should the nurse include in the teaching?
- A. Bathe your baby immediately after a feeding.
- B. Place a bumper pad in your baby’s crib.
- C. Put a soft mattress in your baby’s crib.
- D. Wash your baby’s face with plain water.
Correct Answer: D
Rationale: The correct answer is D: Wash your baby's face with plain water. This instruction is important because it helps prevent irritation or infection on the baby's delicate skin. Washing the baby's face with plain water is gentle and safe for newborns.
A: Bathing the baby immediately after a feeding is not recommended as it may lead to discomfort or spitting up.
B: Placing a bumper pad in the baby's crib can pose a suffocation hazard for the newborn.
C: Putting a soft mattress in the baby's crib increases the risk of sudden infant death syndrome (SIDS) as it may cause suffocation.
Overall, washing the baby's face with plain water is the safest and most appropriate instruction for home safety with a 2-day postpartum client.
A nurse is caring for a client who is at 20 weeks of gestation and has trichomoniasis. Which of the following findings should the nurse expect?
- A. Thick, white vaginal discharge
- B. Urinary frequency
- C. Vulva lesions
- D. Malodorous discharge
Correct Answer: D
Rationale: The correct answer is D: Malodorous discharge. Trichomoniasis is a sexually transmitted infection caused by a parasite, leading to a foul-smelling vaginal discharge. At 20 weeks of gestation, the nurse should expect this symptom due to the infection. Thick, white vaginal discharge (choice A) is more indicative of a yeast infection. Urinary frequency (choice B) is not typically associated with trichomoniasis. Vulva lesions (choice C) are more commonly seen in herpes infection. Therefore, the malodorous discharge (choice D) aligns with the expected finding in a client with trichomoniasis at 20 weeks of gestation.
A nurse is obtaining a 2-hr postprandial blood glucose from a client. Which of the following actions should the nurse take?
- A. Puncture the finger while still damp with antiseptic solution.
- B. Smear the blood onto the reagent strip.
- C. Hold the finger above the heart prior to puncture.
- D. Select the lateral side of the finger for puncture.
Correct Answer: D
Rationale: The correct answer is D: Select the lateral side of the finger for puncture. This is important because the lateral side has fewer nerve endings, making it less painful for the client. Additionally, it reduces the risk of injury to the nerves and blood vessels located on the other sides of the finger. Puncturing the finger while still damp with antiseptic solution (choice A) can dilute the blood sample and affect accuracy. Smearing the blood onto the reagent strip (choice B) may lead to inaccurate results due to improper application. Holding the finger above the heart prior to puncture (choice C) can increase blood flow and potentially affect the glucose level. Therefore, selecting the lateral side of the finger for puncture is the best practice for obtaining a 2-hr postprandial blood glucose sample.