A nurse is reinforcing discharge instructions about breastfeeding with a client. Which of the following statements should the nurse make?
- A. You should recognize that your baby sucking on his hands is a hunger cue.
- B. You should feed your baby for 10 minutes on each breast.
- C. You should feed your baby six times a day.
- D. You should wake your baby at least every 6 hours at night for feedings.
Correct Answer: A
Rationale: Recognizing that sucking on hands is a hunger cue helps ensure timely feeding, supporting a successful breastfeeding routine and adequate nutrition for the baby.
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A nurse is contributing to the plan of care for a newborn who requires phototherapy for hyperbilirubinemia.
Which of the following interventions should the nurse recommend including in the plan?
- A. Reposition the newborn every 2 to 3 hr.
- B. Monitor the newborn's blood glucose level every 2 hr.
- C. Give the newborn 30 ml of distilled water after each feeding.
- D. Apply a water-based ointment to the newborn's skin every 4 to 6 hr.
Correct Answer: A
Rationale: Repositioning the newborn every 2 to 3 hours helps ensure uniform exposure to the phototherapy lights, maximizing the effectiveness of the treatment. This prevents uneven distribution of light and reduces the risk of pressure ulcers or skin breakdown from prolonged immobility.
A nurse is reinforcing teaching about preventing mastitis with a client who is breastfeeding.
Which of the following instructions should the nurse include?
- A. Wear an underwire bra between feedings.
- B. You should use a breast pump if you plan to return to work.
- C. Wash your nipples with soap and water daily.
- D. Cover your breasts immediately after feedings.
Correct Answer: B
Rationale: Using a breast pump prevents engorgement when returning to work, reducing mastitis risk by maintaining milk flow and supply.
A nurse is assisting with the care of a client who is in labor and has an epidural infusion for pain management. The client's blood pressure is 80/40 mm Hg.
Which of the following actions should the nurse take?
- A. Assist the client to empty her bladder.
- B. Place the client in knee chest position
- C. Administer methylergonovine IM
- D. Give a bolus of lactated Ringer's
Correct Answer: D
Rationale: The client's blood pressure is low (80/40 mm Hg), indicating hypotension, a common side effect of epidural anesthesia during labor. Administering a bolus of intravenous fluids, such as lactated Ringer's solution, is the initial intervention to increase intravascular volume, improving blood pressure and perfusion to vital organs.
A nurse is reinforcing teaching with a client who is at 10 weeks of gestation regarding the purposes of laboratory tests.
Which of the following statements by the client indicates an understanding of the teaching?
- A. White blood cell count is an indicator of anemia.
- B. Urine specific gravity identifies my risk for pregnancy induced hypertension
- C. Platelet count identifies if I am at risk for bleeding
- D. Sedimentation rate checks for signs of cancer
Correct Answer: C
Rationale: Platelet count identifies bleeding risk by assessing clotting ability, a key concern in pregnancy, showing the client understands the test's purpose accurately.
A charge nurse is discussing risk factors for postpartum hemorrhage with a newly licensed nurse.
Which of the following conditions should the nurse include as a risk factor?
- A. Retained placental fragments
- B. Urinary tract infection
- C. Oligohydramnios
- D. Breech presentation
Correct Answer: A
Rationale: Retained placental fragments can lead to postpartum hemorrhage due to incomplete expulsion, causing ongoing bleeding. Failure of the uterus to contract effectively increases bleeding risk, making it a significant factor.
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