Nokea
A nurse is reviewing discharge instructions with the parents of a newborn. Which of the following statements indicates a need for further teaching?
- A. We will place the baby on its back to sleep
- B. We will give the baby a pacifier at bedtime
- C. We will keep the baby's crib free of blankets and toys
- D. We will leave the baby's diaper off to prevent diaper rash
Correct Answer: D
Rationale: Leaving a baby's diaper off to prevent diaper rash is not recommended because it increases the risk of infection. Proper diaper hygiene and frequent diaper changes are more effective in preventing diaper rash.
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To decrease the incidence of sudden infant death syndrome (SIDS), the parents will position the newborn in a:
- A. Prone position
- B. Supine position
- C. Side-lying position
- D. Semi-fowler's position
Correct Answer: B
Rationale: The safest sleeping position for infants is on their back (supine position). This reduces the risk of sudden infant death syndrome (SIDS), as sleeping in other positions can increase the risk of airway obstruction.
During a breast examination on a 24-year-old client the nurse notes the following findings. Which finding is of most concern and should be reported to the provider?
- A. An irregularly shaped, nontender lump is palpable in the right breast
- B. Tenderness is present during menstruation
- C. Bilateral, symmetrical lumps that move with palpation
- D. The client reports breast tenderness before menstruation
Correct Answer: A
Rationale: An irregularly shaped, nontender lump is a concerning finding because it may indicate breast cancer. The nurse should report this finding to the provider for further investigation.
A nurse is teaching a client about using an intrauterine device (IUD) for contraception. Which of the following client statements indicate an understanding of the teaching?
- A. I will need to have the IUD replaced each year.
- B. I will need to apply a spermicide prior to intercourse.
- C. I should expect my periods to stop while I have the IUD.
- D. I should check for the string each month after menstruation.
Correct Answer: D
Rationale: The client should check for the string each month after menstruation to ensure the IUD is in place. Regular checks can help identify any displacement.
A client is in active labor and is receiving an epidural for pain relief. Which of the following should the nurse monitor as the priority?
- A. Fetal heart rate
- B. Client's blood pressure
- C. Client's respiratory rate
- D. Client's pain level
Correct Answer: B
Rationale: The most common side effect of an epidural is hypotension, which can compromise placental perfusion. Monitoring the client's blood pressure is the priority to ensure maternal and fetal well-being.
A nurse is discussing recommendations for daily nutrient intake during pregnancy with a client who is at 10 weeks of gestation. For which of the following nutrients should the nurse instruct the client to increase intake during pregnancy?
- A. Vitamin E
- B. Vitamin D
- C. Fiber
- D. Calcium
Correct Answer: D
Rationale: Calcium is vital during pregnancy for fetal bone development and to prevent maternal bone loss. The recommended daily intake should be increased to support these needs.