A nurse is providing teaching to a client who is breastfeeding and experiencing engorgement. Which of the following recommendations should the nurse include?
- A. Apply warm compresses on the breasts before feedings
- B. Allow the infant to nurse on one breast per feeding.
- C. Take aspirin to reduce pain and swelling.
- D. Wear a tight-fitting underwire bra.
Correct Answer: A
Rationale: Warm compresses help to relieve engorgement by promoting milk flow and reducing discomfort before feedings.
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Which of the following is a potential complication of maternal obesity during pregnancy?
- A. Gestational diabetes
- B. Preterm labor
- C. Placental abruption
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D, "All of the above." Maternal obesity during pregnancy can lead to gestational diabetes due to insulin resistance, preterm labor due to increased risk of premature birth, and placental abruption due to higher rates of hypertension and vascular complications. Choosing A, B, or C individually would be incorrect as they are all potential complications associated with maternal obesity.
A nurse is assessing a client who is postpartum following a cesarean birth. The client states, 'I feel like I have to urinate but I can’t go.' Which of the following actions should the nurse take?
- A. Assist the client to ambulate to the bathroom
- B. Insert an indwelling urinary catheter
- C. Perform a bladder scan to assess for urinary retention
- D. Administer a diuretic
Correct Answer: A
Rationale: The correct answer is A: Assist the client to ambulate to the bathroom. This action helps in promoting normal voiding patterns post-cesarean birth. Ambulation can aid in relieving pressure on the bladder, stimulating the urge to urinate, and facilitating the flow of urine. It also promotes circulation, which can help in reducing the risk of urinary retention.
Choice B: Inserting an indwelling urinary catheter should not be the initial intervention as it carries a risk of introducing infection and may not be necessary at this point.
Choice C: Performing a bladder scan can be considered if the client is unable to void after ambulation and other interventions have been attempted.
Choice D: Administering a diuretic is not appropriate in this situation as the client is experiencing difficulty in urinating rather than retaining excessive urine.
In summary, assisting the client to ambulate to the bathroom is the most appropriate initial action to address the client's complaint and promote normal voiding.
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. Place newborn skin to skin on birthing parents chest, Encourage birthing parents to breastfeed, Obtain prescription for arterial blood gases, Plan to initiate phototherapy, Perform neonatal abstinence system scoring
- B. Cold stress, Acute bilirubin encephalopathy, Respiratory distress syndrome, Neonatal abstinence syndrome (NAS)
- C. Stool output, Temperature, Lung sounds, Blood glucose level, Bilirubin level
Correct Answer:
Rationale:
A nurse is caring for a client who is hypotensive following the administration of epidural anesthesia. Which of the following actions should the nurse take?
- A. Turn the client to a side-lying position.
- B. Apply oxygen at 2 L/min via nasal cannula.
- C. Massage the client’s fundus.
- D. Assist the client to empty their bladder.
Correct Answer: A
Rationale: The correct answer is A: Turn the client to a side-lying position. This helps to improve blood flow and circulation, which can help increase blood pressure in a hypotensive client. Placing the client on their side also helps prevent potential complications such as supine hypotension syndrome.
Choice B is incorrect because administering oxygen may not directly address the underlying cause of hypotension in this situation.
Choice C is incorrect as massaging the fundus is typically done to assess postpartum bleeding in women who have recently given birth, not for hypotension following epidural anesthesia.
Choice D is incorrect because while emptying the bladder can help in some cases of hypotension, it may not be the most immediate or appropriate action in this scenario.
Which of the following is a potential ethical issue related to neonatal intensive care?
- A. Allocation of resources
- B. Withholding or withdrawing life-sustaining treatment
- C. Use of alternative therapies without informed consent
- D. All of the above
Correct Answer: D
Rationale: All of the above are potential ethical issues in neonatal intensive care. Allocation of resources raises questions about fairness, withholding or withdrawing treatment involves difficult decisions about quality of life, and using alternative therapies without consent violates patient autonomy.