Nokea
A nurse is teaching a new parent about breastfeeding her 2-week-old infant. Which of the following statements by the parent indicates an understanding of the teaching?
- A. After 5 to 10 minutes when the breast is emptied, my baby should be removed from the breast.
- B. Manually expressing my milk will decrease my milk supply.
- C. My baby should always start on the same breast when feeding.
- D. The more my baby is at the breast sucking, the more milk I will produce.
Correct Answer: D
Rationale: Frequent breastfeeding stimulates milk production, ensuring an adequate milk supply for the infant.
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Which of the following is a potential complication of postpartum depression?
- A. Poor bonding with the newborn
- B. Insufficient milk production
- C. Increased risk of postpartum hemorrhage
- D. All of the above
Correct Answer: A
Rationale: The correct answer is A: Poor bonding with the newborn. Postpartum depression can hinder the mother's ability to emotionally connect with her baby, leading to poor bonding. This can impact the baby's development and the mother's ability to provide adequate care. Choice B is incorrect as milk production is more related to physical factors rather than mental health. Choice C is incorrect as postpartum hemorrhage is a separate medical issue. Choice D is incorrect as it includes all options, which is not accurate in this case.
Complete the following sentence by using the list of options. Based on the client findings, the nurse should first admister-----------------and then prepare to administer-----------------------
- A. calcium gluconate
- B. hydralazine
- C. nifedipine
Correct Answer: B,A
Rationale: Rationale:
First administer hydralazine ✅
The client is experiencing severe hypertension (BP 170/112 mm Hg at 1400), which indicates preeclampsia with severe features.
Hydralazine is a fast-acting antihypertensive that helps lower blood pressure and reduce the risk of stroke, placental abruption, or fetal compromise.
Then prepare to administer calcium gluconate ✅
If the client is receiving magnesium sulfate for seizure prevention (common in severe preeclampsia), calcium gluconate is the antidote in case of magnesium toxicity (which can cause respiratory depression or cardiac arrest).
The nurse should have calcium gluconate readily available in case of toxicity signs like loss of deep tendon reflexes, respiratory depression, or cardiac arrhythmias.
Notify the provider 🚨
The severely elevated BP (170/112 mm Hg) and potential risk for eclampsia (seizures) require immediate provider notification for further management.
A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?
- A. Maintain the client NPO throughout the procedure.
- B. Place the client in a supine position.
- C. Instruct the client to massage the abdomen to stimulate fetal movement.
- D. Instruct the client to press the provided button each time fetal movement is detected.
Correct Answer: D
Rationale: Pressing the button each time fetal movement is detected helps monitor fetal well-being by correlating movement with heart rate accelerations, which is the purpose of a nonstress test.
A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect?
- A. Minimal arm recoil
- B. Popliteal angle of 90°
- C. Creases over the entire foot sole
- D. Raised areolas with 3 to 4 mm buds
Correct Answer: A
Rationale: The correct answer is A: Minimal arm recoil. In premature newborns, the lack of muscle tone results in minimal arm recoil, which is a characteristic finding in the New Ballard Score for assessing gestational age. This is due to the immaturity of the neuromuscular system in premature infants. Choice B, popliteal angle of 90°, is incorrect as flexion of the hips and knees is more common in preterm infants. Choice C, creases over the entire foot sole, is incorrect as full development of foot sole creases is seen in term infants. Choice D, raised areolas with 3 to 4 mm buds, is incorrect as these are signs of breast development and are not specific to gestational age assessment.
Which of the following is a potential complication of neonatal hyperbilirubinemia?
- A. Dehydration
- B. Kernicterus
- C. Hypoglycemia
- D. All of the above
Correct Answer: B
Rationale: Neonatal hyperbilirubinemia can lead to kernicterus, a severe form of brain damage caused by high bilirubin levels.