Nokea
A nurse is caring for a client who is experiencing sore nipples from breastfeeding. Which of the following actions should the nurse take?
- A. Place a snug dressing on the client’s nipple when not breastfeeding
- B. Ensure the newborn’s mouth is wide open before latching to the breast
- C. Encourage the client to limit the newborn’s feeding to 10 min on each breast
- D. Instruct the client to begin the feeding with the nipple that is most tender
Correct Answer: B
Rationale: The correct answer is B: Ensure the newborn’s mouth is wide open before latching to the breast. This is the correct action to take to address sore nipples from breastfeeding. Ensuring a wide latch helps the baby to properly attach to the breast, reducing the pressure on the nipple and preventing further damage. A snug dressing (Option A) can worsen the condition by obstructing airflow and promoting moisture. Limiting feeding time (Option C) can lead to inadequate milk supply or poor weight gain. Starting with the most tender nipple (Option D) can prolong healing.
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A nurse is providing teaching to a client who is receiving medroxyprogesterone IM for contraception. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should discontinue this medication if I experience spotting
- B. I will need to return to the clinic in the next eight weeks for my next injection
- C. I should increase my calcium intake while taking this medication
- D. I will get two shots each time I receive this medication
Correct Answer: B
Rationale: The correct answer is B. Returning to the clinic in 8 weeks for the next injection indicates an understanding of the medication schedule. Medroxyprogesterone is typically given every 11 to 13 weeks, so returning in 8 weeks would align with the correct timing for the next injection. This demonstrates the client's comprehension of the dosing regimen.
Incorrect choices:
A: Discontinuing the medication if spotting occurs is not correct as spotting can be a common side effect of medroxyprogesterone.
C: Increasing calcium intake is not specifically related to medroxyprogesterone IM for contraception.
D: Getting two shots each time is incorrect as typically only one injection is given.
Overall, choice B is the correct answer based on the medication's dosing schedule, while the other choices do not align with the appropriate understanding of medroxyprogesterone IM for contraception.
A nurse is developing an educational program about hemolytic diseases in newborns for a group of newly licensed nurses. Which of the following genetic information should the nurse include in the program as a cause of hemolytic disease?
- A. The mother is Rh positive, and the father is Rh negative
- B. The mother is Rh negative, and the father is Rh positive
- C. The mother and the father are both Rh positive
- D. The mother and the father are both Rh negative
Correct Answer: B
Rationale: The correct answer is B: The mother is Rh negative, and the father is Rh positive. Hemolytic disease in newborns is caused by Rh incompatibility, where the mother is Rh negative and the father is Rh positive. This leads to the mother developing antibodies against the Rh-positive fetal red blood cells, resulting in hemolysis in the fetus. The other choices are incorrect because Rh incompatibility occurs when the mother is Rh negative and the father is Rh positive, not when both parents are Rh positive (choice C) or both are Rh negative (choice D). This educational program should emphasize the importance of Rh factor compatibility in preventing hemolytic disease in newborns.
A nurse is caring for a client following a vaginal delivery of a term fetal demise. Which of the following statement should the nurse make?
- A. “You can bathe and dress your baby if you’d like to.”
- B. “If you don’t hold the baby, it will make letting go much harder.”
- C. “You should name the baby so she can have an identity.”
- D. “I’m sure you will be able to have another baby when you’re ready.”
Correct Answer: A
Rationale: The correct answer is A, as it encourages the client to make decisions based on their preferences. By stating, "You can bathe and dress your baby if you’d like to," the nurse offers support and control to the client during a difficult time. This empowers the client to engage in meaningful rituals and take control of the situation.
Choice B is incorrect because it imposes guilt on the client by suggesting that not holding the baby will make letting go harder, which may not be the case for everyone. Choice C is incorrect as naming the baby should be a personal decision and not a directive from the nurse. Choice D is incorrect because it assumes the client's readiness for another baby, which may not be the case and can be insensitive.
A nurse is caring for a client who is receiving oxytocin to induce labor. The nurse should discontinue the oxytocin if which of the following occurs?
- A. Contractions last 60 seconds
- B. Non-repetitive early decelerations
- C. 6 contractions in 10 minutes
- D. Moderate variability of the fetal heart rate
Correct Answer: A
Rationale: The correct answer is A: Contractions last 60 seconds. Prolonged contractions can lead to uterine hyperstimulation, which can decrease oxygen supply to the fetus, posing a risk of fetal distress. Discontinuing oxytocin in this situation is crucial to prevent further complications.
B: Non-repetitive early decelerations are not directly related to oxytocin administration and do not warrant discontinuation of the medication.
C: 6 contractions in 10 minutes is a sign of uterine hyperstimulation but alone may not be enough to discontinue oxytocin.
D: Moderate variability of the fetal heart rate is a reassuring sign of fetal well-being, not an indication to discontinue oxytocin.
A nurse is caring for a client who has received an epidural during labor. Which of the following actions should the nurse take?
- A. Position a wedge under the clients left hip
- B. Place the client in the lithotomy position
- C. Assist the client to a knee chest position
- D. Elevate the head of the client’s bed to 90%
Correct Answer: A
Rationale: The correct answer is A: Position a wedge under the client's left hip. Placing a wedge under the left hip helps to optimize the distribution of the epidural medication, ensuring even pain relief. This positioning can also help prevent uneven spread of the medication, reducing the risk of complications such as uneven numbness or motor weakness.
Choice B: Placing the client in the lithotomy position is incorrect because this position is not recommended for clients with epidurals as it may increase the risk of hypotension.
Choice C: Assisting the client to a knee-chest position is incorrect because this position is not suitable for clients with epidurals and may cause discomfort or compromise the effectiveness of the epidural.
Choice D: Elevating the head of the client's bed to 90% is incorrect as it is not directly related to optimizing the effects of the epidural.
In summary, positioning a wedge under the client's left hip is the most appropriate action to ensure optimal distribution and effectiveness