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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 a client following a vegan diet. Vitamin B12 is primarily found in animal products, so vegans need to ensure they get an adequate intake from fortified foods or supplements. Raw carrots (B), fresh citrus fruits (C), and brown rice (D) do not contain significant amounts of vitamin B12 and would not be effective in increasing intake. A detailed explanation is crucial in guiding the client to make informed choices for their dietary needs.
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A nurse is collecting data from a client who is at 30 weeks of gestation. Which of the following findings should the nurse identify as a manifestation of pyelonephritis?
- A. Epigastric discomfort
- B. Flank pain
- C. Temperature 37.7°C (99.8°F)
- D. Abdominal cramping
Correct Answer: B
Rationale: The correct answer is B: Flank pain. Pyelonephritis is a kidney infection commonly characterized by flank pain, which is a key symptom. Flank pain is typically located on the side of the body between the upper abdomen and the back. This pain occurs due to inflammation of the kidney tissues. The other choices are incorrect because: A) Epigastric discomfort is more indicative of issues related to the upper abdomen, such as gastritis or pancreatitis. C) A temperature of 37.7°C (99.8°F) is slightly elevated but not specific to pyelonephritis. D) Abdominal cramping is more suggestive of gastrointestinal issues like gas or constipation. Therefore, the presence of flank pain is the most relevant finding to identify pyelonephritis in a client at 30 weeks of gestation.
A nurse is teaching about home safety with a client who is 2 days postpartum. Which of the following instructions should the nurse include in the teaching?
- A. Bathe your baby immediately after a feeding.
- B. Place a bumper pad in your baby’s crib.
- C. Put a soft mattress in your baby’s crib.
- D. Wash your baby’s face with plain water.
Correct Answer: D
Rationale: The correct answer is D: Wash your baby's face with plain water. This instruction is important because it helps prevent irritation or infection on the baby's delicate skin. Washing the baby's face with plain water is gentle and safe for newborns.
A: Bathing the baby immediately after a feeding is not recommended as it may lead to discomfort or spitting up.
B: Placing a bumper pad in the baby's crib can pose a suffocation hazard for the newborn.
C: Putting a soft mattress in the baby's crib increases the risk of sudden infant death syndrome (SIDS) as it may cause suffocation.
Overall, washing the baby's face with plain water is the safest and most appropriate instruction for home safety with a 2-day postpartum client.
A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching?
- A. Mothers will receive prophylactic treatment with acyclovir prior to delivery.
- B. Transmission can occur via the saliva and urine of the newborn.
- C. Lesions are visible on the mother’s genitalia.
- D. This infection requires that airborne precautions be initiated for the newborn.
Correct Answer: B
Rationale: The correct answer is B: Transmission can occur via the saliva and urine of the newborn. Maternal cytomegalovirus can be transmitted to the newborn through contact with infected bodily fluids such as saliva and urine. This is important for the nurses to understand as they care for both the mother and the newborn to prevent transmission.
Choice A is incorrect because acyclovir is not used to treat cytomegalovirus, but rather for other viral infections like herpes. Choice C is incorrect because lesions are not typically visible on the mother's genitalia with cytomegalovirus. Choice D is incorrect because airborne precautions are not necessary for cytomegalovirus transmission.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
- A. Initiate anticoagulant therapy, Administer an oxytocic medication, Apply ice packs to the breasts.
- B. Engorgement, Urinary tract infection, Deed vein thrombosis
- C. Temperature, Circumference of lower extremities, Integrity of the nipples
Correct Answer:
Rationale: Correct Answer: Action to Take: A, B; Potential Condition: B; Parameter to Monitor: C, E.
Rationale:
1. Potential Condition: Engorgement is a common condition postpartum characterized by breast fullness and tenderness.
2. Actions to Take: Initiate anticoagulant therapy to prevent deep vein thrombosis and administer an oxytocic medication to relieve engorgement.
3. Parameters to Monitor: Circumference of lower extremities (for DVT) and integrity of the nipples (for engorgement). These parameters will help assess the client's progress in managing these conditions effectively.
A nurse is teaching about car seat safety to the parents of a newborn who was delivered at 38 weeks of gestation. Which of the following statements by a parent indicates an understanding of the teaching?
- A. I can use a sleep sack to keep my baby warm in the car seat.'
- B. My baby will need a car seat challenge test before discharge.'
- C. The car seat should be positioned in the car at a 45-degree angle.'
- D. When my baby is 1 year old, I can turn their car seat facing forward.'
Correct Answer: C
Rationale: Correct Answer: C - The car seat should be positioned in the car at a 45-degree angle.
Rationale: Placing the car seat at a 45-degree angle helps protect a newborn's airway and prevents slumping, ensuring optimal safety during travel. This position aligns the baby's head with the neck and spine, reducing the risk of suffocation and injury in the event of sudden stops or accidents. A 45-degree angle also supports proper breathing and oxygenation for the newborn. Therefore, this statement indicates the parent understands the importance of correctly positioning the car seat for their baby's safety.
Summary of Incorrect Choices:
A: Incorrect - Using a sleep sack in the car seat can lead to overheating and compromise the baby's safety by interfering with the car seat's harness system.
B: Incorrect - A car seat challenge test is typically done for premature infants, not a newborn delivered at 38 weeks of gestation.
D: Incorrect - Turning a baby's car seat forward-facing