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. Feed the newborn 5 to 10 min per breast.
- B. Offer the newborn 30 mL (1 oz) of water between feedings.
- C. Expect two to four wet diapers every 24 hr.
- D. Allow the baby to feed at least every 3 hr.
Correct Answer: D
Rationale: The correct answer is D: Allow the baby to feed at least every 3 hours. This is crucial for maintaining the baby's nutrition and ensuring an adequate milk supply. Breastfeeding on demand helps establish a healthy feeding pattern and promotes bonding between the mother and baby. Option A is incorrect because newborns should feed until they are satisfied, not based on time. Option B is incorrect as newborns should not be given water as it can interfere with breastfeeding and lead to water intoxication. Option C is incorrect as newborns should have at least 6-8 wet diapers a day.
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A nurse is providing prenatal teaching to a client who practices a vegan diet and is trying to increase intake of vitamin B12. Which of the following foods should the nurse recommend?
- A. Fortified soy milk
- B. Raw carrots
- C. Fresh citrus fruits
- D. Brown rice
Correct Answer: A
Rationale: The correct answer is A: Fortified soy milk. Soy milk is often fortified with vitamin B12, making it a suitable option for vegans. Vitamin B12 is primarily found in animal products, so vegans need to rely on fortified foods or supplements. Raw carrots (B), fresh citrus fruits (C), and brown rice (D) do not contain significant amounts of vitamin B12 and are not suitable sources for increasing intake. It is important for the nurse to recommend a specific food that is known to be fortified with vitamin B12 to meet the client's dietary needs.
A nurse is caring for a client who is 1 hr postpartum and has uterine atony. The client is exhibiting a large amount of vaginal bleeding. Which of the following actions should the nurse take?
- A. Administer betamethasone IM.
- B. Avoid performing sterile vaginal examinations.
- C. Anticipate a prescription for misoprostol.
- D. Obtain a specimen for a Kleihauer-Betke test.
Correct Answer: C
Rationale: The correct answer is C: Anticipate a prescription for misoprostol. Misoprostol is a medication commonly used to manage postpartum hemorrhage due to uterine atony. It helps to promote uterine contractions and control bleeding. Administering betamethasone (A) is not indicated in this situation as it is a steroid used for fetal lung maturation. Avoiding sterile vaginal examinations (B) may delay the identification of the cause of bleeding. Obtaining a specimen for a Kleihauer-Betke test (D) is used to determine the amount of fetal-maternal hemorrhage and is not the immediate priority in managing uterine atony.
A nurse is preparing to perform Leopold maneuvers on a client who is at 36 weeks of gestation. Identify the sequence of actions the nurse should take.
- A. Instruct the client to empty their bladder.
- B. Position the client supine with knees flexed and place a small, rolled towel under one of their hips.
- C. Palpate the fetal part positioned in the fundus.
- D. Palpate the fetal parts along both sides of the uterus.
Correct Answer: A, B, C, D
Rationale: Action to Take: A, B; Potential Condition: C; Parameter to Monitor: D, E.
The correct sequence of actions for performing Leopold maneuvers includes:
A) Instruct the client to empty their bladder to enhance visualization and palpation accuracy.
B) Position the client supine with knees flexed to provide access and comfort for the client during the procedure.
C) Palpate the fetal part positioned in the fundus to determine the baby's presentation and position.
D) Palpate the fetal parts along both sides of the uterus to assess the location and movement of the fetus.
It is important to follow these steps to accurately assess the fetal position and presentation. Other choices are incorrect as they do not align with the standard procedure for Leopold maneuvers.
A nurse is caring for a client who is at 37 weeks of gestation and is being tested for group B streptococcus ß-hemolytic (GBS). The client is multigravida and multipara with no history of GBS. She asks the nurse why the test was not conducted earlier in her pregnancy. Which of the following is an appropriate response by the nurse?
- A. You didn't report any symptoms of GBS during your pregnancy.'
- B. Your previous deliveries were all negative for GBS.'
- C. There was no indication of GBS in your earlier prenatal testing.'
- D. We need to know if you are positive for GBS at the time of delivery.'
Correct Answer: D
Rationale: The correct answer is D: We need to know if you are positive for GBS at the time of delivery. This is the most appropriate response because GBS status can change throughout pregnancy, and the risk of transmitting GBS to the newborn is highest during delivery. Testing closer to the due date ensures the most accurate results.
A: Incorrect. GBS may not present with symptoms, so relying on symptoms alone is not a reliable method for testing.
B: Incorrect. Previous negative results do not guarantee current status, as GBS status can change.
C: Incorrect. Lack of indication in earlier prenatal testing does not rule out GBS at the time of delivery.
E, F, G: Not provided, but unnecessary as the correct answer has been identified.
A nurse is caring for a client who is 12 hr postpartum and has a fourth-degree laceration of the perineum. Which of the following actions should the nurse take?
- A. Apply a moist, warm compress to the perineum.
- B. Provide the client with a cool sitz bath.
- C. Administer methylergonovine 0.2 mg IM.
- D. Apply povidone-iodine to the client’s perineum after she voids.
Correct Answer: A
Rationale: The correct answer is A: Apply a moist, warm compress to the perineum. This action helps to reduce pain and swelling, promotes healing, and improves comfort. Moist heat increases blood flow to the area, which can aid in the healing process.
Choice B: Providing a cool sitz bath may provide some relief from discomfort, but warm compresses are more effective for promoting healing in this case.
Choice C: Administering methylergonovine is not indicated for a fourth-degree perineal laceration. This medication is used to prevent or control postpartum hemorrhage.
Choice D: Applying povidone-iodine to the perineum is not recommended as it may cause irritation and delay healing.
In summary, choice A is the most appropriate action as it promotes healing and comfort for the client with a fourth-degree perineal laceration. Choices B, C, and D are not recommended in this situation.