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 hr. This instruction is important for establishing and maintaining a good milk supply, promoting proper infant growth and development, and preventing common breastfeeding issues like engorgement and mastitis. Feeding on demand also helps ensure the baby receives enough nutrients and helps establish a strong breastfeeding relationship.
A: Feed the newborn 5 to 10 min per breast - This is incorrect as it may not allow the baby to get enough hindmilk, which is essential for proper growth.
B: Offer the newborn 30 mL (1 oz) of water between feedings - Giving water to newborns can interfere with breastfeeding and may lead to water intoxication.
C: Expect two to four wet diapers every 24 hr - While monitoring diaper output is important, this alone does not provide adequate guidance on feeding frequency.
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A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first?
- A. A client who is at 11 weeks of gestation and reports abdominal cramping
- B. A client who is at 15 weeks of gestation and reports tingling and numbness in right hand
- C. A client who is at 20 weeks of gestation and reports constipation for the past 4 days
- D. A client who is at 8 weeks of gestation and reports having three bloody noses in the past week
Correct Answer: A
Rationale: The correct answer is A: A client who is at 11 weeks of gestation and reports abdominal cramping. Abdominal cramping in early pregnancy can be a sign of ectopic pregnancy, miscarriage, or other complications requiring immediate attention. The nurse should see this client first to assess the situation and provide appropriate interventions.
Choice B is incorrect because tingling and numbness in the right hand is not typically an urgent issue in pregnancy. Choice C is incorrect as constipation, while uncomfortable, is not an immediate concern that requires urgent attention. Choice D is incorrect as bloody noses can be common in pregnancy due to increased blood volume and nasal congestion, but it does not require immediate attention unless severe or persistent.
A nurse is administering a hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?
- A. Administer the injection into the vastus lateralis muscle.
- B. Vigorously massage the site following the injection.
- C. Insert the needle at a 45° angle for injection.
- D. Use a 21-gauge needle for the injection.
Correct Answer: A
Rationale: The correct answer is A: Administer the injection into the vastus lateralis muscle. This is the recommended site for administering vaccines to newborns due to the large muscle mass, reducing the risk of injury to nerves and blood vessels. It also allows for proper absorption of the vaccine. Option B is incorrect as vigorous massage can lead to tissue damage and discomfort. Option C is incorrect as the needle should be inserted at a 90° angle for intramuscular injections. Option D is incorrect as a smaller gauge needle (typically 25-27 gauge) is recommended for newborns to minimize pain and tissue trauma.
A nurse is planning care for a client who is 1 hr postpartum and has peripartum cardiomyopathy. Which of the following actions should the nurse plan to take?
- A. Obtain a prescription for misoprostol.
- B. Assess blood pressure twice daily.
- C. Restrict daily oral fluid intake.
- D. Administer an IV bolus of lactated Ringer's.
Correct Answer: B
Rationale: The correct answer is B: Assess blood pressure twice daily. In a client with peripartum cardiomyopathy, monitoring blood pressure is crucial to detect worsening heart function and potential complications. Assessing blood pressure twice daily allows for early detection of hypertension or hypotension, which can indicate cardiac decompensation. Misoprostol (Choice A) is not indicated in this scenario. Restricting fluid intake (Choice C) can lead to dehydration and worsen the client's condition. Administering an IV bolus of lactated Ringer's (Choice D) may not be appropriate without assessing the client's fluid status first.
A nurse is caring for a client who is receiving an epidural block with an opioid analgesic. The nurse should monitor for which of the following findings as an adverse effect of the medication?
- A. Hyperglycemia
- B. Bilateral crackles
- C. Hypotension
- D. Polyuria
Correct Answer: C
Rationale: The correct answer is C: Hypotension. Opioid analgesics can cause vasodilation, leading to a drop in blood pressure. The nurse should monitor for hypotension as a potential adverse effect, as this can result in dizziness and decreased perfusion. Hyperglycemia (A) is not typically associated with opioid analgesics. Bilateral crackles (B) are more indicative of fluid overload or pulmonary edema. Polyuria (D) is excessive urination and is not a common adverse effect of opioid analgesics.
A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?
- A. Maintain the client NPO throughout the procedure.
- B. Place the client in a supine position.
- C. Instruct the client to massage the abdomen to stimulate fetal movement.
- D. Instruct the client to press the provided button each time fetal movement is detected.
Correct Answer: D
Rationale: The correct answer is D: Instruct the client to press the provided button each time fetal movement is detected. This action is essential during a nonstress test as it helps to monitor the baby's heart rate in response to its movements, providing crucial information about fetal well-being. Pressing the button allows the nurse to correlate fetal movements with changes in the heart rate, helping to assess the baby's overall health and response to stimuli. Maintaining the client NPO (A) is not necessary for a nonstress test. Placing the client in a supine position (B) can decrease blood flow to the baby and is not recommended. Instructing the client to massage the abdomen (C) may artificially stimulate fetal movements, affecting the accuracy of the test results.