Nokea
A nurse is caring for a client who is postpartum and breastfeeding. Which of the following instructions should the nurse provide to prevent mastitis?
- A. Feed the newborn on demand
- B. Apply warm compresses to the breast before feeding
- C. Massage the breast after feedings
- D. Ensure the newborn empties one breast before switching to the other
Correct Answer: D
Rationale: To prevent mastitis, the nurse should instruct the client to ensure that the newborn empties one breast before switching to the other. This helps to prevent milk stasis, reducing the risk of inflammation and infection. Choice A is incorrect because feeding on demand is recommended to establish a good milk supply and prevent engorgement. Choice B is incorrect as warm compresses are usually applied before feeding to promote milk flow. Choice C is incorrect because massaging the breast after feedings can actually increase the risk of mastitis by causing further irritation.
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A nurse is assessing a client who is in active labor. The client reports the urge to have a bowel movement and begins to bear down during contractions. Which of the following actions should the nurse take?
- A. Instruct the client to perform rapid, shallow breathing
- B. Prepare the client for an emergency cesarean birth
- C. Have the client perform pelvic tilts during contractions
- D. Apply counterpressure to the client's sacrum
Correct Answer: A
Rationale: The correct answer is to instruct the client to perform rapid, shallow breathing. The urge to bear down during contractions indicates the second stage of labor, and pushing prematurely can lead to complications. Rapid, shallow breathing helps prevent pushing until the cervix is fully dilated. Choice B is incorrect because preparing for an emergency cesarean birth is not indicated based on the information provided. Choice C is incorrect as pelvic tilts are not appropriate when the client is already bearing down. Choice D is incorrect since applying counterpressure to the sacrum is not the priority when the client is showing signs of advancing labor.
A nurse is assessing a client who is at 35 weeks of gestation and has suspected placenta previa. Which of the following findings should the nurse expect?
- A. Painless vaginal bleeding
- B. Severe abdominal pain
- C. Uterine contractions
- D. Increased fetal movement
Correct Answer: A
Rationale: Correct. Placenta previa typically presents with painless vaginal bleeding as the placenta is located over or near the cervical opening. This bleeding occurs because the placental vessels are stretched and bleed easily. Severe abdominal pain (choice B) is not a typical finding in placenta previa. Uterine contractions (choice C) are more characteristic of preterm labor rather than placenta previa. Increased fetal movement (choice D) is not a specific finding associated with placenta previa.
A client in the first stage of labor is experiencing lower back pain and asks the nurse what can be done to relieve the pain. Which of the following interventions should the nurse suggest?
- A. Perform effleurage on the client's abdomen
- B. Apply counterpressure to the client's sacrum
- C. Provide a back massage with lavender oil
- D. Administer opioid analgesics
Correct Answer: B
Rationale: Applying counterpressure to the sacrum can help alleviate lower back pain during labor by reducing pressure on the nerves. Effleurage on the abdomen, back massage with lavender oil, and administering opioid analgesics are not specifically targeted at relieving lower back pain, making them less effective interventions in this scenario.
A nurse is assessing a client who is at 32 weeks of gestation. Which of the following findings should the nurse report to the provider?
- A. Client reports constipation
- B. Client reports swelling in the face
- C. Client reports heartburn
- D. Client reports frequent urination
Correct Answer: B
Rationale: The correct answer is B because facial swelling can indicate preeclampsia, a serious condition during pregnancy that requires immediate medical attention. Constipation (choice A), heartburn (choice C), and frequent urination (choice D) are common discomforts during pregnancy and are not typically indicative of a serious complication like preeclampsia at 32 weeks of gestation.
A nurse is teaching a client who is at 20 weeks of gestation about the glucose tolerance test. Which of the following instructions should the nurse include?
- A. You should eat a low-carbohydrate diet for 3 days before the test.
- B. You will need to fast for 12 hours before the test.
- C. You should expect the test to take about 1 hour.
- D. You will need to limit fluid intake to water before the test.
Correct Answer: C
Rationale: The correct answer is C. During a glucose tolerance test, the client is required to drink a glucose solution, and blood samples are taken at specific intervals, typically over a period of 1 to 3 hours. In this case, the nurse should inform the client to expect the test to take about 1 hour. Choices A, B, and D are incorrect because there is no specific instruction to eat a low-carbohydrate diet for 3 days before the test, fast for 12 hours before the test, or limit fluid intake to water before the test in a standard glucose tolerance test.