Nokea
A nurse is planning to teach a group of clients who are about breastfeeding after returning to work. Which of the following infection should the nurse include in the teaching?
- A. "Thawed breast milk can be refrigerated for up to 72 hours."
- B. "Breast milk can be stored in a deep freezer for 12 months."
- C. Breast milk can be stored at room temperature for up to 12 hours."
- D. "Thawed breast milk that is unused can be refrozen."
Correct Answer: D
Rationale: The correct information for breastfeeding after returning to work is that thawed breast milk that is unused should not be refrozen. Once breast milk has been thawed, it should be used within 24 hours and should not be refrozen. This is important to prevent contamination and maintain the quality of the breast milk for the baby. The other statements provided in the options are correct guidelines regarding the storage of breast milk. Thawed breast milk can be refrigerated for up to 24 hours, breast milk can be stored in a deep freezer for up to 12 months, and breast milk can be stored at room temperature for up to 4 hours.
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Multiparous patient admitted to labor unit with regular contractions 2 minutes apart and last 60 seconds. She reports labor began 6 hours ago and she had bloody show earlier this morning.The patient asks what stage of labor she is in
- A. Transition phase
- B. Active phase
- C. Latent phase
- D. Second stage
Correct Answer: B
Rationale: Based on the information provided, the patient is experiencing regular contractions 2 minutes apart lasting 60 seconds, and she had a bloody show earlier in the morning. These signs in a multiparous patient with 6 hours of labor indicate she is most likely in the transition phase of labor. The transition phase is characterized by intense contractions that are closer together, typically 2-3 minutes apart, and lasting longer, usually around 60-90 seconds. This stage signifies the progression towards the final stages of labor, leading up to the pushing stage and delivery. Therefore, the correct answer is B, Transition phase.
What is considered the first day of the menstrual cycle?
- A. day of ovulation
- B. first day of menstrual bleeding
- C. last day of menstrual bleeding
- D. when the corpus luteum forms
Correct Answer: B
Rationale:
Three hours after birth, a newborn of a mother with diabetes becomes jittery, has weak, high- pitched cry , and exhibits irregular respirations. The nurse recognizes that these signs are often associated with:
- A. Hypovolemia
- B. Hypocalcemia
- C. Hypoglycemia
- D. Hyperglycemia
Correct Answer: C
Rationale: The signs described in the scenario - jitteriness, weak high-pitched cry, irregular respirations - are indicative of hypoglycemia in a newborn. Babies born to mothers with diabetes are at risk for hypoglycemia due to their exposure to high blood sugar levels in utero. After birth, when the baby is separated from the mother's blood supply, their own insulin production may lead to a sudden drop in blood glucose levels.
The nurse is explaining how a newly delivered baby initiates respiration. Which statement explains this process?
- A. Chemical thermal and mechanical factors
- B. Increase of po2 and decreased pco2
- C. Continued function of foramen ovale
- D. Drying off the infant
Correct Answer: A
Rationale: The correct statement explaining how a newly delivered baby initiates respiration is "Chemical thermal and mechanical factors." When a baby is born, various factors come into play to stimulate the baby's first breath. Chemically, the baby senses a decrease in oxygen and an increase in carbon dioxide levels, triggering the respiratory centers in the brain to start the breathing process. Thermally, exposure to the cooler air outside the womb stimulates the baby's skin receptors, encouraging the baby to take a breath. Mechanically, the pressure changes during delivery and the physical stimulation of the baby's face and body also play a role in initiating respiration. Overall, it is the combined effect of these chemical, thermal, and mechanical factors that help a newly delivered baby begin breathing independently.
During a nursing assessment the woman with rupture
- A. What is the nurse's priority action?
- B. Use gravity and manipulation to relieve compression of the cord (butt up in the air and face down until ready to delivery)
- C. Help the fetal head descend faster
- D. Facilitate dilation of the cervix with prostaglandin gel
Correct Answer: A
Rationale: In the scenario presented, the nurse's priority action should be to call for emergent medical assistance. A woman with a rupture during a nursing assessment could be experiencing a serious complication known as umbilical cord prolapse. This occurs when the umbilical cord slips through the cervix ahead of the baby, which can lead to compression of the cord and a serious decrease in oxygen supply to the baby. It is a medical emergency that requires immediate intervention by the healthcare team, which may include moving the mother into a knee-chest position or performing a cesarean section. Therefore, the priority action for the nurse is to ensure prompt medical intervention to protect the well-being of both the mother and the baby.