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A nurse is teaching about home safety with a client who is 2 days postpartum. Which of the following instructions should the nurse include in the teaching?
- A. Bathe your baby immediately after a feeding.
- B. Place a bumper pad in your baby’s crib.
- C. Put a soft mattress in your baby’s crib.
- D. Wash your baby’s face with plain water.
Correct Answer: D
Rationale: The correct answer is D: Wash your baby's face with plain water. This instruction is important because newborns have sensitive skin that can easily become irritated by soaps or cleansers. Using plain water is gentle and safe for the baby's delicate skin. Additionally, washing the baby's face helps to keep the area clean and prevent any buildup of milk or debris that can lead to skin irritation or infections.
Choice A is incorrect because bathing a baby immediately after a feeding can increase the risk of spitting up or discomfort due to handling on a full stomach. Choice B is incorrect as bumper pads pose a suffocation risk for infants. Choice C is incorrect because a soft mattress can increase the risk of Sudden Infant Death Syndrome (SIDS).
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A nurse is planning care for a client who is 1 hr postpartum and has peripartum cardiomyopathy. Which of the following actions should the nurse plan to take?
- A. Obtain a prescription for misoprostol.
- B. Assess blood pressure twice daily.
- C. Restrict daily oral fluid intake.
- D. Administer an IV bolus of lactated Ringer's.
Correct Answer: B
Rationale: The correct answer is B: Assess blood pressure twice daily. This is crucial as peripartum cardiomyopathy can lead to heart failure and hypertension, affecting the client's blood pressure. Monitoring blood pressure twice daily allows for early detection of any changes and timely intervention. Obtaining a prescription for misoprostol (A) is not indicated as it is used for preventing gastric ulcers, not related to peripartum cardiomyopathy. Restricting oral fluid intake (C) may worsen the client's condition as adequate hydration is important for cardiac function. Administering an IV bolus of lactated Ringer's (D) could potentially worsen fluid overload and exacerbate heart failure.
A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take?
- A. Replace the surgical dressing.
- B. Evaluate urinary output.
- C. Apply an ice pack to the incision site.
- D. Administer 500 mL lactated Ringer’s IV bolus.
Correct Answer: D
Rationale: The correct answer is D: Administer 500 mL lactated Ringer’s IV bolus. This action is appropriate as the client is experiencing postpartum hemorrhage, which can lead to hypovolemic shock. Administering IV fluids helps increase circulating volume and stabilize the client's condition. The other choices are incorrect because: A) Replacing the surgical dressing does not address the underlying issue of hemorrhage. B) Evaluating urinary output is important but not the priority when the client is actively bleeding. C) Applying an ice pack to the incision site is not indicated and may not address the hemorrhage. Overall, choice D is the most crucial intervention to address the immediate concern of postpartum hemorrhage.
A nurse is providing teaching to a client who is at 35 weeks of gestation and has a prescription for an amniocentesis. Which of the following client statements indicates an understanding of the teaching?
- A. I should empty my bladder before the procedure.
- B. I will be lying on my side during the procedure.
- C. I will be asleep during the procedure.
- D. I should start fasting 24 hours before the procedure.
Correct Answer: A
Rationale: The correct answer is A. Emptying the bladder before amniocentesis helps prevent injury to the bladder during the procedure. This statement shows understanding of the importance of bladder emptying for safety and accuracy.
B: Incorrect. The client is typically lying on their back during amniocentesis.
C: Incorrect. The client is awake during the procedure.
D: Incorrect. Fasting is not required for amniocentesis.
A nurse is teaching about car seat safety to the parents of a newborn who was delivered at 38 weeks of gestation. Which of the following statements by a parent indicates an understanding of the teaching?
- A. I can use a sleep sack to keep my baby warm in the car seat.'
- B. My baby will need a car seat challenge test before discharge.'
- C. The car seat should be positioned in the car at a 45-degree angle.'
- D. When my baby is 1 year old, I can turn their car seat facing forward.'
Correct Answer: C
Rationale: The correct answer is C because positioning the car seat at a 45-degree angle is important for newborns to prevent their head from falling forward and potentially obstructing their airway. This angle helps keep the baby safe and secure during the ride.
Choice A is incorrect because using a sleep sack in the car seat can interfere with the harness straps and compromise the baby's safety.
Choice B is incorrect as a car seat challenge test is conducted for preterm infants, not infants born at 38 weeks of gestation.
Choice D is incorrect because it is recommended to keep infants in a rear-facing position until they reach the height or weight limit specified by the car seat manufacturer, typically around 2 years old.
A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?
- A. Administer broad-spectrum antibiotics.
- B. Monitor the rectal temperature every 4 hr.
- C. Cleanse the site with povidone-iodine.
- D. Prepare for surgical closure after 72 hr.
Correct Answer: A
Rationale: The correct answer is A: Administer broad-spectrum antibiotics. This is crucial for preventing infection due to the leakage of cerebrospinal fluid, which can lead to meningitis. Antibiotics will help reduce the risk of infection until surgical repair can be done. Monitoring rectal temperature (B) is not directly related to addressing the myelomeningocele. Cleansing the site with povidone-iodine (C) may further irritate the area. Surgical closure (D) should not be delayed, as infection risk is high.