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Client who is breastfeeding and has mastitis.
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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Client at 34 weeks of gestation scheduled for a nonstress test.
A nurse is providing teaching to a client who is at 34 weeks of gestation and is scheduled for a nonstress test. Which of the following statements should the nurse plan to make?
- A. You will receive a medication through an IV for this test.
- B. You should expect the test to take about 30 minutes.
- C. You should not eat or drink for 4 hours prior to the test.
- D. This test will help determine if your baby's lungs are mature.
Correct Answer: B
Rationale: Nonstress tests typically last about 20–40 minutes, depending on fetal activity and reactivity. This duration allows sufficient time to observe fetal heart rate accelerations.
Client with fibrocystic breast changes experiencing breast discomfort during menstruation.
A nurse is providing teaching to a client who has fibrocystic breast changes and is experiencing breast discomfort during menstruation. Which of the following instructions should the nurse include?
- A. Increase your potassium intake.
- B. Increase your fluid intake to 3 liters per day.
- C. Refrain from consuming alcohol.
- D. Limit your daily intake of fiber.
Correct Answer: C
Rationale: Alcohol consumption can worsen fibrocystic breast discomfort due to its estrogen-modulating effects, which may exacerbate hormonal fluctuations during menstruation, increasing breast pain and sensitivity.
Client receiving oxytocin to augment labor, nurse notes recurrent variable decelerations of the FHR.
A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations of the FHR. Which of the following actions should the nurse take first?
- A. Prepare the necessary equipment to initiate an amnioinfusion.
- B. Assist with performing a vaginal/speculum exam to check for a prolapsed umbilical cord.
- C. Discontinue the infusion of oxytocin.
- D. Provide instructions for the client about potential preparation for birth.
Correct Answer: C
Rationale: Discontinuing oxytocin reduces uterine contractions, alleviating cord compression and improving fetal oxygenation, which is the first step in managing recurrent variable decelerations of fetal heart rate.
Client gave birth 1 week ago, states: 'I don't know what's wrong. I love my baby, but I feel so let down and I seem to cry for no reason.'
A nurse is assessing a client who gave birth 1 week ago. The client states, 'I don't know what's wrong. I love my baby, but I feel so let down and I seem to cry for no reason.' The nurse should identify that the client is experiencing which of the following emotional responses to birth?
- A. Postpartum depression.
- B. Taking-in phase.
- C. Postpartum blues.
- D. Taking-hold phase.
Correct Answer: C
Rationale: Postpartum blues, characterized by mood swings, crying spells, and irritability, typically resolve within two weeks postpartum and are linked to hormonal changes.
Client in active labor with early decelerations of the FHR on the fetal monitor tracing.
A nurse is caring for a client who is in active labor. The nurse notes early decelerations of the FHR on the fetal monitor tracing. The nurse should identify that which of the following conditions causes early decelerations in the FHR?
- A. Fetal hypoxemia.
- B. Uteroplacental insufficiency.
- C. Cord compression.
- D. Head compression.
Correct Answer: D
Rationale: Early decelerations result from fetal head compression, stimulating the vagus nerve and leading to transient heart rate decreases. This is common during contractions.