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A nurse is providing discharge instructions to a client who is breastfeeding her newborn.
- 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.) of water between feedings
- D. Feed the newborn 5 to 10 minutes per breast
Correct Answer: B
Rationale: The correct answer is B: Allow the baby to feed at least every 3 hours. This is important for maintaining the baby's hydration, ensuring proper nutrition, and promoting successful breastfeeding. Feeding on demand helps establish a good milk supply and supports the baby's growth and development. Offering water (choice C) is unnecessary and can interfere with breastfeeding. Limiting feeding time to 5-10 minutes per breast (choice D) can prevent the baby from getting enough hindmilk, which is rich in fat and important for weight gain. Expecting 2-4 wet diapers every 24 hours (choice A) is a general guideline but not as crucial as ensuring frequent feedings for a breastfeeding newborn.
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A nurse on a labor and delivery unit is receiving infection control standards with a newly licensed nurse. The nurse should instruct the newly licensed nurse to don gloves for which of the following procedures?
- A. Assisting a mother with breastfeeding
- B. Performing a newborn’s initial bath
- C. Administering the measles, mumps, rubella vaccine
- D. Performing umbilical cord care
Correct Answer: D
Rationale: The correct answer is D: Performing umbilical cord care. Gloves should be worn when performing this procedure to prevent potential infection transmission. The umbilical cord stump is a point of entry for pathogens, making it important to maintain strict infection control. Assisting a mother with breastfeeding (A) does not require gloves unless there are open wounds or sores on the mother's breast. Performing a newborn’s initial bath (B) does not necessitate gloves unless there are specific concerns like skin conditions. Administering the measles, mumps, rubella vaccine (C) typically requires clean, not sterile, technique. In summary, wearing gloves during umbilical cord care is essential to prevent infection transmission, making it the correct choice in this scenario.
A nurse is providing discharge teaching to a postpartum client about caring for her five-day-old male newborn at home.
- 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 because adequate urine output is a sign of good hydration and kidney function in newborns. Notifying the pediatrician if the baby urinates less than 6 times a day can help identify any potential issues early on.
Choice A is incorrect because retracting the foreskin to clean the baby's penis is not recommended as it can lead to infections.
Choice B is incorrect because using triple antibiotic ointment on the umbilical cord is not necessary and can actually delay healing.
Choice C is incorrect because swaddling the baby tightly with legs extended can increase the risk of hip dysplasia.
Overall, it is important to focus on monitoring the baby's urine output and notifying the pediatrician if there are any concerns.
A nurse is caring for a client who has maternal hypotension following the placement of an epidural. Which of the following actions should the nurse take?
- A. Give terbutaline Subq
- B. Position the client in a knee chest position
- C. Apply oxygen via nonrebreather
- D. Administer a bolus of lactated ringer
Correct Answer: D
Rationale: The correct answer is D: Administer a bolus of lactated Ringer. Maternal hypotension following epidural placement indicates hypovolemia or vasodilation. Providing a bolus of lactated Ringer helps increase intravascular volume, improving blood pressure. Terbutaline Subq (A) is not indicated for hypotension. Positioning the client in a knee-chest position (B) is not appropriate for maternal hypotension. Applying oxygen via non-rebreather (C) may not address the underlying cause of hypotension.
A nurse in a provider’s office is assessing a client at her first antepartum visit. The client states that the first day of her last menstrual period was March 8. Use Negele’s rule to calculate the estimated date of delivery. (Use the MMDD format with four numerals and no spaces or punctuation.)
- A. December 15
- B. October 30
- C. January 15
- D. Nov 30
Correct Answer: A
Rationale: To calculate the estimated due date using Negele's rule, we add 7 days to the first day of the last menstrual period, subtract 3 months, and then add a year. March 8 + 7 days = March 15. Subtracting 3 months gives us December 15. Adding a year gives the estimated due date as December 15. This is the correct answer as it follows the standard calculation method. Other choices are incorrect as they do not follow the correct formula or have errors in calculation.
A nurse is teaching a prenatal class regarding false labor. Which of the following information should the nurse include?
- A. your contraction will become more intense when walking
- B. you will have dilation and effacement of the cervix
- C. You will have bloody show
- D. Your contraction will become temporally regular
Correct Answer: A
Rationale: The correct answer is A: your contractions will become more intense when walking. This is because false labor contractions typically decrease in intensity or stop completely when the individual changes positions or engages in physical activity. This is a key characteristic that helps differentiate false labor from true labor. Choices B, C, and D are incorrect as they are more indicative of true labor, where there is cervical dilation, effacement, bloody show, and regular contractions. It is important for the nurse to emphasize this distinction to ensure pregnant individuals can recognize the signs of true labor and seek appropriate care.