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A nurse is planning care for a client who is breastfeeding and has mastitis. Which of the following interventions should the nurse include?
- A. Instruct the client to wash their hands prior to breastfeeding.
- B. Teach the client about proper latching-on techniques.
- C. Encourage the client to alternate breastfeeding with formula feeding.
- D. Encourage the client to allow their nipples to air dry after feedings.
Correct Answer: A,B,D
Rationale: Handwashing (A) minimizes pathogen transmission. Proper latching techniques (B) reduce nipple trauma and facilitate milk drainage. Allowing nipples to air dry (D) promotes healing and reduces infection risk.
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A nurse is caring for a client who has a prescription for ibuprofen to treat postpartum cramping. Which of the following questions should the nurse ask prior to administering the medication?
- A. Are you taking over-the-counter medications?
- B. Do you have a history of gastric problems?
- C. What kind of contraception will you be using?
- D. Are you being treated for high blood pressure?
Correct Answer: A
Rationale: Ibuprofen can interact with various over-the-counter medications, including anticoagulants and corticosteroids, which may increase risks of side effects like gastrointestinal bleeding or reduced efficacy, necessitating careful assessment of concurrent drug use.
A nurse is assessing a newborn who is 48 hr old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome?
- A. Hyporeactivity.
- B. Excessive high-pitched cry.
- C. Acrocyanosis.
- D. Respiratory rate of 50/min.
Correct Answer: B
Rationale: Excessive high-pitched crying results from central nervous system hyperirritability caused by withdrawal. Neonatal abstinence syndrome involves exaggerated responses to stimuli, reflecting the neonate's difficulty in self-regulation.
A nurse is caring for a client who is postpartum, has a deep-vein thrombosis, and is receiving heparin therapy via subcutaneous injections. Which of the following actions should the nurse take?
- A. Request a prescription for PRN aspirin from the provider.
- B. Massage the injection site thoroughly following administration.
- C. Instruct the client that they cannot breastfeed while receiving heparin.
- D. Administer the injection in the client's abdomen.
Correct Answer: D
Rationale: The abdomen is the preferred site for subcutaneous heparin injections due to its fatty tissue, which minimizes risks of intramuscular bleeding and ensures consistent drug absorption.
A nurse is caring for a client who is pregnant for the fourth time. The client delivered two full-term newborns and had one spontaneous abortion at 10 weeks of gestation. The nurse should document the client's obstetrical history as which of the following?
- A. Gravida 3, Para 2.
- B. Gravida 3, Para 3.
- C. Gravida 4, Para 2.
- D. Gravida 4, Para 3.
Correct Answer: C
Rationale: Gravida 4 reflects the client's total pregnancies, including the current one and her abortion, while Para 2 accounts for her two full-term live births, accurately documenting her obstetrical history.
A nurse is teaching the parents of a newborn how to care for their child's uncircumcised penis. Which of the following instructions should the nurse include?
- A. Retract the foreskin until you feel resistance.
- B. Use a cotton swab to clean under the foreskin.
- C. Apply petroleum jelly to the foreskin.
- D. Wash the penis once per day with soap and water.
Correct Answer: D
Rationale: Daily washing with mild soap and water ensures proper hygiene and prevents infection. This method maintains cleanliness without causing harm to sensitive tissues.