Nokea
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.
You may also like to solve these questions
A nurse is caring for a client who is 36 weeks gestation and has MRSA. Which of the following isolation precautions should the nurse initiate?
- A. Droplet
- B. Contact
- C. Airborne
- D. Protective environment
Correct Answer: B
Rationale: The correct answer is B: Contact precautions. MRSA is primarily spread through direct contact with an infected person or contaminated surfaces. By implementing contact precautions, the nurse can prevent the transmission of MRSA to other patients or healthcare workers. Droplet precautions (choice A) are used for diseases spread via respiratory droplets, such as influenza. Airborne precautions (choice C) are for diseases transmitted through small particles in the air, like tuberculosis. Protective environment (choice D) is used for immunocompromised patients to protect them from environmental pathogens. In this scenario, contact precautions are the most appropriate choice to prevent the spread of MRSA.
A nurse is assessing a client who is in preterm labor and has a new prescription or terbutaline 0.25 mg subcutaneous. For which of the following findings should the nurse Withhold the medication and Report to the provider?
- A. Fasting blood glucose 75 mg / DL
- B. Blood pressure 88/58 mmhg
- C. Urinary output 40 ml /hr
- D. FHR 120/min
Correct Answer: B
Rationale: The correct answer is B: Blood pressure 88/58 mmHg. Terbutaline is a tocolytic medication used to stop preterm contractions. A low blood pressure reading of 88/58 mmHg may indicate hypotension, a potential side effect of terbutaline. Hypotension can lead to decreased placental perfusion, putting the fetus at risk. The nurse should withhold the medication and report this finding to the provider for further assessment and intervention.
A: Fasting blood glucose of 75 mg/dL is within normal range and does not require withholding the medication.
C: Urinary output of 40 ml/hr is adequate and does not indicate a need to withhold the medication.
D: Fetal heart rate of 120/min is within the normal range for a fetus and does not require withholding the medication.
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.
A nurse is assessing a client who is 27 weeks of gestation and has pre eclampsia. Which of the following findings should the nurse report to the provider?
- A. Hemoglobin 14.8 g/dL
- B. Platelet count 60,000/ mm
- C. Creatine 0.8 mg/ dL
- D. Urine protein concentration 200 mg/24hr
Correct Answer: B
Rationale: The correct answer is B: Platelet count 60,000/ mm. In pre-eclampsia, a low platelet count indicates thrombocytopenia, a serious complication that can lead to bleeding. This finding should be reported promptly to the provider for further evaluation and management. A: Hemoglobin level is within normal range and not a priority in pre-eclampsia. C: Creatinine level is normal and not directly related to the complications of pre-eclampsia. D: Urine protein concentration is elevated, which is expected in pre-eclampsia and should be monitored, but not as urgent as low platelet count.
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.