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A nurse is observing a new guardian caring for their crying newborn who is bottle feeding. Which of the following actions by the guardian should the nurse recognize as a positive parenting behavior?
- A. Lays the newborn across their lap and gently sways.
- B. Places the newborn in the crib in a prone position.
- C. Offers the newborn a pacifier dipped in formula.
- D. Prepares a bottle of formula mixed with rice cereal.
Correct Answer: A
Rationale: Laying the newborn across the lap and gently swaying is a positive parenting behavior that can help soothe the newborn and promote bonding.
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For each potential assessment finding, click to specity if the assessment finding Is consistent with mastitis or endometritis. Each finding may support more than 1 disease process.
- A. Foul-smelling lochia
- B. Painful, tender breast
- C. Temperature
- D. Chilis
Correct Answer:
Rationale:
A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?
- A. Reassess the client in 2 hr.
- B. Administer simethicone.
- C. Assist the client to empty their bladder.
- D. Instruct the client to lie on their right side.
Correct Answer: C
Rationale: Correct Answer: C - Assist the client to empty their bladder.
Rationale: The client's uterus palpated to the right above the umbilicus indicates a full bladder displacing the uterus. A distended bladder can prevent the uterus from contracting effectively, leading to increased risk of postpartum hemorrhage. Emptying the bladder helps the uterus contract properly, reducing the risk of complications. This intervention directly addresses the underlying issue.
Incorrect Choices:
A: Reassessing in 2 hours does not address the immediate concern of a full bladder causing uterine displacement.
B: Simethicone is used for gas relief and is not relevant in this situation.
D: Instructing the client to lie on their right side does not address the bladder distention issue.
E, F, G: Irrelevant as they do not address the specific problem of a full bladder causing uterine displacement.
What is the recommended method of pain relief during labor for a woman who desires systemic opioids?
- A. Intravenous opioids
- B. Intramuscular opioids
- C. Oral opioids
- D. All of the above
Correct Answer: A
Rationale: Intravenous opioids are the recommended method for systemic pain relief during labor.
A nurse in a clinic is caring for a 16-year-old adolescent. Which of the following findings should the nurse report to the provider? (Select all that apply.)
- A. Abdominal assessment
- B. Vaginal discharge
- C. Heart rate
- D. Temperature
- E. Dyspareunia
- F. Condom usage
Correct Answer: A,B,D,E,F
Rationale: The correct findings to report to the provider are A, B, D, E, and F. Abdominal assessment (A) is important to assess for any underlying issues. Vaginal discharge (B) could indicate infection. Temperature (D) may suggest infection or illness. Dyspareunia (E) could indicate underlying gynecological issues. Condom usage (F) is important for assessing sexual activity and risk. Heart rate (C) is a normal vital sign and doesn't necessarily require immediate reporting.
A nurse is assessing a newborn who has neonatal abstinence syndrome. Which of the following findings should the nurse expect?
- A. Diminished deep tendon reflexes
- B. Excessive crying
- C. Decreased muscle tone
- D. Absent Moro reflex
Correct Answer: B
Rationale: The correct answer is B: Excessive crying. Neonatal abstinence syndrome (NAS) occurs in newborns exposed to addictive substances in utero. The newborn may exhibit symptoms such as excessive crying due to neurologic irritability. Diminished deep tendon reflexes (A) are not typically associated with NAS. Decreased muscle tone (C) is not a common finding in NAS; infants may actually have increased muscle tone. An absent Moro reflex (D) is not a typical finding in NAS, as hyperreflexia is more common.