Nokea
A nurse is preparing to perform a fundal massage for a postpartum client with hearing seeing uterine atony. In which order should the nurse plan to perform the following actions? (molded steps into the box on the right. Placing them in order of performance use all steps)
- A. Ask the client to lie on her back in with her knees flexed
- B. Position one hand around the top of the client9s when fundus in one hand just above the client's symphysis pubis
- C. Rotate the upper hand to massage that clients uterus while using slight downward pressure to compress the fundus
- D. observe the client's perineum for the passage of clots and the amount of bleeding
Correct Answer: A,B,C,D
Rationale: Correct order of actions for fundal massage:
A: Ask the client to lie on her back with knees flexed - This position allows easy access to the uterus.
B: Position one hand around the top of the client's fundus and one hand just above the symphysis pubis - Proper positioning ensures effective massage.
C: Rotate the upper hand to massage the client's uterus while using slight downward pressure to compress the fundus - This helps to stimulate contraction and control bleeding.
D: Observe the client's perineum for the passage of clots and the amount of bleeding - Monitoring for complications is essential.
Summary:
E: Not applicable - No action specified.
F: Not applicable - No action specified.
G: Not applicable - No action specified.
Incorrect choices:
The other choices are incorrect as they do not follow the logical sequence required for performing a fundal massage effectively and safely.
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A nurse is providing discharge teaching to a postpartum client about caring for her five-year 5day old male newborn at home. Which of the following statements should the nurse make to the client?
- A. Retract the foreskin to clean your baby's penis during each bath
- B. Use triple antibiotic ointment on your baby's umbilical cord twice per day
- C. Swaddle your baby tightly with legs extended before laying him down to sleep
- D. Notify your baby's pediatrician if he urinates less than 6 times per day
Correct Answer: D
Rationale: The correct answer is D: Notify your baby's pediatrician if he urinates less than 6 times per day. This is important as decreased urine output can indicate dehydration in a newborn, which is a serious concern. It is crucial to monitor the baby's hydration status closely in the early days of life.
A: Retracting the foreskin to clean the baby's penis is not recommended as it can cause harm and is not necessary at this age.
B: Using triple antibiotic ointment on the umbilical cord is not recommended as it can delay the natural healing process.
C: Swaddling the baby tightly with legs extended is not recommended as it can increase the risk of hip dysplasia.
In summary, the other choices are incorrect because they may cause harm or are not recommended practices for caring for a newborn.
A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following instructions should the nurse include?
- A. Expect 2 to 4 wet diapers every 24 hours
- B. Allow the baby to feed at least every 3 hours
- C. Offer the newborn 30 ml (1 oz.) a water between feedings
- D. Feed the newborn 5 to 10 minutes per breast
Correct Answer: B
Rationale: Correct Answer: B - Allow the baby to feed at least every 3 hours.
Rationale:
1. Breastfeeding frequency is crucial for establishing a good milk supply and ensuring the baby receives adequate nutrition.
2. Newborns typically need to breastfeed at least 8-12 times in 24 hours to meet their nutritional needs.
3. Feeding every 3 hours helps maintain the baby's hydration, energy levels, and growth.
4. Regular feeding also helps prevent issues like engorgement for the mother and ensures the baby gets enough hindmilk for proper growth.
Summary of Incorrect Choices:
A: Wet diapers may vary, but newborns should ideally have 8-12 wet diapers a day.
C: Offering water between feedings is unnecessary and may fill up the baby's stomach, reducing milk intake.
D: Limiting feeding time per breast may not allow the baby to get enough hindmilk, essential for growth and development.
A nurse is planning care for a newborn who is scheduled to start phototherapy using a lap. Which of the following actions should the nurse include?
- A. Apply a thin layer lotion to the newborn skin every 8 hours
- B. Trust in you born in a thin layer clothing during the therapy
- C. Ensure the newborn's eyes are closed beneath the shield
- D. Give the newborn 1 oz of glucose water every 4 hours
Correct Answer: C
Rationale: The correct answer is C: Ensure the newborn's eyes are closed beneath the shield. This is crucial during phototherapy to protect the newborn's eyes from potential damage caused by the bright lights. Newborns undergoing phototherapy should have their eyes shielded with protective eye coverings to prevent eye damage. Choice A is incorrect as lotion can intensify the effects of phototherapy. Choice B is incorrect as the newborn should be undressed to maximize skin exposure. Choice D is incorrect as glucose water is not indicated for phototherapy and may interfere with treatment.
The nurse is teaching a client and her partner about the technique of counter pressure during labor. Which of the following statements by the nurse is appropriate?
- A. Your partner will apply upward pressure on your lower abdomen between contractions
- B. Your partner will apply continuous from pressure between your thumb and index finger
- C. Your partner will apply pressure to the top of your uterus during contractions
- D. Your partner will apply steady pressure with a tennis ball to your lower back
Correct Answer: D
Rationale: The correct answer is D because applying steady pressure with a tennis ball to the lower back can help relieve lower back pain during labor. This technique targets the sacral area, which can alleviate discomfort and provide comfort. Choice A is incorrect as upward pressure on the lower abdomen may not be effective for pain relief. Choice B is incorrect as applying continuous pressure between the thumb and index finger is not related to counter pressure for labor pain. Choice C is incorrect as pressure on the top of the uterus during contractions is not a recommended technique.
A nurse is assessing a full-term newborn arm admission to the nursery. Which of the following clinical findings should the nurse report to the provider?
- A. Transient circumoral cyanosis - i think this is referring to acrocyanosis which is normal
- B. Single Palmar creases - down syndrome - p.27
- C. Subconjunctival hemorrhage - expected
- D. Rust stain urine - expected
Correct Answer: B
Rationale: The correct answer is B: Single Palmar creases - down syndrome. This finding should be reported to the provider because it is a physical characteristic associated with Down syndrome. The presence of a single palmar crease can indicate a chromosomal abnormality and requires further evaluation.
A: Transient circumoral cyanosis is a common finding in newborns and is typically related to acrocyanosis, which is considered normal in the immediate postnatal period.
C: Subconjunctival hemorrhage is a common occurrence during the birth process and is often benign, resolving on its own without intervention.
D: Rust stain urine may be a result of uric acid crystals and is considered expected in newborns due to the metabolism of fetal hemoglobin. It does not typically require immediate reporting to the provider.
In summary, the other choices are considered normal or expected in newborns, while the presence of a single palmar crease requires further assessment due to its association with Down syndrome.