Nokea
A nurse is providing teaching to a client who is receiving medroxyprogesterone IM for contraception. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should discontinue this medication if I experience spotting
- B. I will need to return to the clinic in the next eight weeks for my next injection
- C. I should increase my calcium intake while taking this medication
- D. I will get two shots each time I receive this medication
Correct Answer: C
Rationale: The correct answer is C: "I should increase my calcium intake while taking this medication." This is because medroxyprogesterone can decrease bone density, so increasing calcium intake helps counteract this side effect. Option A is incorrect as spotting is a common side effect and not a reason to discontinue the medication. Option B is incorrect as medroxyprogesterone injections are typically given every 12-13 weeks, not every 8 weeks. Option D is incorrect as only one shot is typically given each time.
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A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following instructions should the nurse include?
- A. Expect 2 to 4 wet diapers every 24 hours
- B. Allow the baby to feed at least every 3 hours
- C. Offer the newborn 30 ml (1 oz.) a water between feedings
- D. Feed the newborn 5 to 10 minutes per breast
Correct Answer: B
Rationale: Correct Answer: B - Allow the baby to feed at least every 3 hours.
Rationale:
1. Breastfeeding frequency is crucial for establishing a good milk supply and ensuring the baby receives adequate nutrition.
2. Newborns typically need to breastfeed at least 8-12 times in 24 hours to meet their nutritional needs.
3. Feeding every 3 hours helps maintain the baby's hydration, energy levels, and growth.
4. Regular feeding also helps prevent issues like engorgement for the mother and ensures the baby gets enough hindmilk for proper growth.
Summary of Incorrect Choices:
A: Wet diapers may vary, but newborns should ideally have 8-12 wet diapers a day.
C: Offering water between feedings is unnecessary and may fill up the baby's stomach, reducing milk intake.
D: Limiting feeding time per breast may not allow the baby to get enough hindmilk, essential for growth and development.
A nurse is observing an adolescent client who is offering her newborn a bottle while he is laying in the bassinet. When the nurse offers to pick the newborn up and place them in the client's arms, the mother States < No, the baby is too tired to be held=. Which of the following actions should the nurse take?
- A. Insist that the mother pick up the newborn to feed him
- B. Demonstrate how to hold a newborn and allow the client to practice
- C. Persuade the client to breastfeed the newborn to promote bonding
- D. Offer to take the newborn to the nursery to finish his feeding
Correct Answer: B
Rationale: The correct answer is B: Demonstrate how to hold a newborn and allow the client to practice. This response promotes education and empowerment by showing the client the proper way to hold and feed the newborn, fostering a supportive and educational environment. Insisting on the mother picking up the newborn (choice A) disregards the mother's wishes and may lead to conflict. Persuading the client to breastfeed (choice C) may not be appropriate if the client has chosen bottle-feeding. Taking the newborn to the nursery (choice D) does not address the client's desire to feed her baby.
A nurse is reviewing the laboratory results of a newborn. Which of the following findings should the nurse report to the provider?
- A. Blood glucose 58 mg / DL
- B. Hematocrit 48%
- C. Platelets 100,000/ mm 3
- D. Hemoglobin 16 G / DL
Correct Answer: C
Rationale: The correct answer is C: Platelets 100,000/mm3. This finding is abnormal in a newborn and could indicate a potential bleeding disorder or thrombocytopenia, which requires immediate attention from the provider to assess and manage appropriately. Choice A (Blood glucose 58 mg/dL) is within normal range for a newborn. Choice B (Hematocrit 48%) and D (Hemoglobin 16 g/dL) are also within normal limits for a newborn and do not require immediate reporting.
A nurse is assessing a newborn whose mother had a primary cytomegalovirus (CMV) infection during pregnancy. The newborn acquired CMV trans placenta Lee. Which of the following findings should the nurse expect the newborn to exhibit?
- A. Urinary tract infection
- B. Hearing loss
- C. Macrosomia
- D. Cataracts
Correct Answer: B
Rationale: The correct answer is B: Hearing loss. CMV infection during pregnancy can lead to congenital CMV in the newborn, causing sensorineural hearing loss. This occurs as the virus affects the inner ear structures. Urinary tract infection (A), macrosomia (C), and cataracts (D) are not typically associated with congenital CMV infection. The nurse should monitor the newborn's hearing closely and consider early intervention if hearing loss is detected.
The nurse is teaching a client and her partner about the technique of counter pressure during labor. Which of the following statements by the nurse is appropriate?
- A. Your partner will apply upward pressure on your lower abdomen between contractions
- B. Your partner will apply continuous from pressure between your thumb and index finger
- C. Your partner will apply pressure to the top of your uterus during contractions
- D. Your partner will apply steady pressure with a tennis ball to your lower back
Correct Answer: D
Rationale: The correct answer is D because applying steady pressure with a tennis ball to the lower back can help relieve lower back pain during labor. This technique targets the sacral area, which can alleviate discomfort and provide comfort. Choice A is incorrect as upward pressure on the lower abdomen may not be effective for pain relief. Choice B is incorrect as applying continuous pressure between the thumb and index finger is not related to counter pressure for labor pain. Choice C is incorrect as pressure on the top of the uterus during contractions is not a recommended technique.