Nokea
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: The correct answer is A: Apply warm compresses on the breasts before feedings. Warm compresses help to promote milk flow and relieve engorgement by increasing blood flow to the area. This can make it easier for the baby to latch and feed effectively. It is important to address engorgement promptly to prevent complications such as blocked ducts or mastitis.
Option B is incorrect because allowing the infant to nurse on one breast per feeding may not fully empty the breasts, leading to further engorgement. Option C is incorrect because aspirin is not recommended during breastfeeding due to potential risks to the infant. Option D is incorrect because wearing a tight-fitting underwire bra can constrict the breasts and worsen engorgement.
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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 could indicate a potential threat of miscarriage or ectopic pregnancy, which require immediate assessment to ensure the safety of the client and the pregnancy. Clients experiencing this symptom need prompt evaluation to rule out any serious complications. Choices B, C, and D do not pose immediate risks to the client or the pregnancy and can be addressed after ensuring the safety of the client in choice A. Numbness and tingling in the hand (choice B) may be due to carpal tunnel syndrome, while constipation (choice C) and bloody noses (choice D) are common pregnancy symptoms that can be managed through non-urgent interventions.
A nurse in a clinic is caring for a 16-year-old adolescent. Which of the following findings should the nurse report to the provider? (Select all that apply.)
- A. Abdominal assessment
- B. Vaginal discharge
- C. Heart rate
- D. Temperature
- E. Dyspareunia
- F. Condom usage
Correct Answer: A,B,D,E,F
Rationale: The correct answers to report to the provider are A, B, D, E, and F. A: Abdominal assessment is crucial to identify any potential underlying issues. B: Vaginal discharge in an adolescent may indicate infection or hormonal imbalance. D: Temperature abnormalities could signal infection. E: Dyspareunia (pain during intercourse) may indicate reproductive health concerns. F: Condom usage is important for safe sex practices. Choices C and G are not specifically related to the adolescent's care needs and do not require immediate reporting.
A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
- A. Identify the attitude of the head.
- B. Palpate the fundus to identify the fetal part.
- C. Determine the location of the fetal back.
- D. Palpate for the fetal part presenting at the inlet.
Correct Answer: B, C, D, A
Rationale: The correct order for performing Leopold maneuvers is B, C, D, A. Firstly, palpating the fundus (B) helps identify the fetal part. Next, determining the location of the fetal back (C) gives insight into the baby's position. Palpating for the fetal part at the inlet (D) helps determine the presenting part. Finally, identifying the attitude of the head (A) concludes the assessment. The other choices do not align with the sequential nature of Leopold maneuvers, making them incorrect.
A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?
- A. Contractions lasting 80 seconds.
- B. Early decelerations in the PHR.
- C. Temperature 37.4° C (99 3* F).
- D. PHR baseline 170/min.
Correct Answer: D
Rationale: The correct answer is D: PHR baseline 170/min. A baseline fetal heart rate of 170/min is considered tachycardia and may indicate fetal distress, requiring immediate attention. This finding can be indicative of fetal hypoxia or other complications. The nurse should report this to the provider promptly for further evaluation and intervention.
Contractions lasting 80 seconds (choice A) are within the normal range for active labor and do not necessarily require immediate reporting.
Early decelerations in the PHR (choice B) are benign and typically not a cause for concern unless they are persistent or associated with other abnormal findings.
A temperature of 37.4°C (99.3°F) (choice C) is within normal limits and does not require immediate reporting unless it continues to rise significantly.
In summary, the correct answer is D because a baseline fetal heart rate of 170/min is abnormal and potentially indicative of fetal distress, requiring immediate provider notification.
A nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take prior to leaving the newborn with their parent?
- A. Ensure that the parent's identification band number matches the newborn's identification band number.
- B. Ask the parent to verify their name and date of birth.
- C. Check the newborn's security tag number to ensure it matches the newborn's medical record.
- D. Match the newborn's date and time of birth to the information in the parent's medical record.
Correct Answer: A
Rationale: The correct answer is A: Ensure that the parent's identification band number matches the newborn's identification band number. This is crucial for proper identification and prevention of mix-ups. Matching the identification bands ensures that the newborn is going to the correct parent, enhancing safety.
Choice B is incorrect because asking the parent to verify their own information does not confirm the identification of the newborn. Choice C is incorrect as it focuses on the security tag number, which may not be as reliable as the identification bands. Choice D is incorrect as matching the date and time of birth to the parent's medical record does not provide direct confirmation of the parent-newborn match.