Nokea
A nurse is caring for a postpartum person who is breastfeeding. What is the most appropriate intervention for sore nipples?
- A. apply lanolin cream
- B. administer IV fluids
- C. perform uterine massage
- D. apply cold compress
Correct Answer: A
Rationale: The correct answer is A: apply lanolin cream. Lanolin cream helps soothe and moisturize sore nipples, providing relief during breastfeeding. It is safe for both the mother and the baby. Applying lanolin cream after each feeding can prevent further irritation and promote healing.
Incorrect choices:
B: Administering IV fluids is not indicated for sore nipples.
C: Performing uterine massage is unrelated to treating sore nipples.
D: Applying cold compress may provide temporary relief but does not address the underlying issue of sore nipples.
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A woman in labor is experiencing severe perineal pressure and the urge to push. What should the nurse assess next?
- A. Cervical dilation
- B. Fetal position
- C. Fetal heart rate
- D. Maternal blood pressure
Correct Answer: A
Rationale: The correct answer is A: Cervical dilation. Assessing cervical dilation is crucial as it indicates the progress of labor and readiness for pushing. The nurse needs to determine if the woman is fully dilated to guide the timing of pushing.
B: Fetal position is important but not the immediate priority when the woman is experiencing the urge to push.
C: Fetal heart rate should be continually monitored during labor but is not the next assessment when the woman has the urge to push.
D: Maternal blood pressure is important but not the immediate concern when the woman is ready to push.
A nurse is caring for a pregnant patient who is at 28 weeks gestation and has a history of hypertension. Which of the following interventions is the most appropriate to prevent complications?
- A. Encourage the patient to increase salt intake to raise blood pressure.
- B. Monitor the patient's blood pressure regularly and check for protein in the urine.
- C. Increase physical activity and exercise to reduce blood pressure.
- D. Limit fluid intake to prevent swelling and lower blood pressure.
Correct Answer: B
Rationale: The correct answer is B: Monitor the patient's blood pressure regularly and check for protein in the urine. This is the most appropriate intervention because the patient has a history of hypertension, which can lead to complications like preeclampsia. Regular blood pressure monitoring and urine protein checks are essential in detecting early signs of preeclampsia, allowing for timely intervention to prevent complications.
Choice A: Encouraging the patient to increase salt intake would worsen hypertension and increase the risk of complications.
Choice C: Increasing physical activity and exercise may not be safe for a pregnant patient with hypertension and can potentially raise blood pressure.
Choice D: Limiting fluid intake can lead to dehydration and is not recommended during pregnancy, especially with a history of hypertension.
A birthing person who delivered a newborn vaginally is receiving care in the labor and birth unit. The health-care provider diagnosed a retained placenta. What is the primary risk associated with a retained placenta?
- A. neonatal jaundice
- B. postpartum hemorrhage
- C. delayed bonding
- D. postpartum anemia
Correct Answer: B
Rationale: The primary risk associated with a retained placenta is postpartum hemorrhage. When the placenta does not deliver completely after childbirth, it can lead to excessive bleeding, risking the mother's health. This condition requires immediate medical attention to prevent severe complications. Neonatal jaundice, delayed bonding, and postpartum anemia are not directly linked to a retained placenta, making them incorrect choices. Neonatal jaundice is caused by elevated bilirubin levels, delayed bonding is related to emotional factors, and postpartum anemia is characterized by low red blood cell count, none of which are the primary risk associated with a retained placenta.
A nurse is preparing to administer a tetanus toxoid vaccine to a postpartum person. What is the nurse's priority action before administering the vaccine?
- A. verify the person's immunization history
- B. obtain informed consent
- C. check for signs of an allergic reaction
- D. ensure proper positioning for the vaccine
Correct Answer: D
Rationale: The correct answer is D: ensure proper positioning for the vaccine. It is essential to ensure the person is in the correct position before administering the vaccine to ensure accurate and safe administration. Proper positioning helps prevent injury and ensures the vaccine is administered correctly. Verifying the person's immunization history (choice A) is important but not the priority before administering the vaccine. Informed consent (choice B) should be obtained but is not the priority action in this scenario. Checking for signs of an allergic reaction (choice C) is important but should be done after ensuring proper positioning for the vaccine.
A woman in her third trimester advises the nurse that she wishes to breastfeed her baby, 'but I don’t think my nipples are right.' Upon examination, the nurse notes that the client has inverted nipples. Which of the following actions should the nurse take at this time?
- A. Advise the client that it is unlikely that she will be able to breastfeed.
- B. Refer the client to a lactation consultant for advice.
- C. Call the labor room and notify them that a client with inverted nipples will be admitted.
- D. Teach the woman exercises to exert her nipples.
Correct Answer: B
Rationale: Inverted nipples can make breastfeeding challenging, but with proper guidance from a lactation consultant, many women are able to breastfeed successfully. Exercises to exert the nipples may also be helpful, but referral to a specialist is the best initial action.