Nokea
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 to prevent skin irritation and infection in newborns. Washing the baby's face with plain water helps to keep the delicate skin clean without introducing any harsh chemicals or irritants. It is gentle and safe for the baby's sensitive skin.
Summary of why the other choices are incorrect:
A: Bathing the baby immediately after a feeding can lead to discomfort and potential issues with digestion.
B: Placing a bumper pad in the baby's crib increases the risk of suffocation and Sudden Infant Death Syndrome (SIDS).
C: Putting a soft mattress in the crib can pose a suffocation hazard and increase the risk of SIDS.
E, F, G: No additional choices provided.
You may also like to solve these questions
A nurse is caring for a client who is at 37 weeks of gestation and is being tested for group B streptococcus ß-hemolytic (GBS). The client is multigravida and multipara with no history of GBS. She asks the nurse why the test was not conducted earlier in her pregnancy. Which of the following is an appropriate response by the nurse?
- A. You didn't report any symptoms of GBS during your pregnancy.'
- B. Your previous deliveries were all negative for GBS.'
- C. There was no indication of GBS in your earlier prenatal testing.'
- D. We need to know if you are positive for GBS at the time of delivery.'
Correct Answer: D
Rationale: The correct answer is D: "We need to know if you are positive for GBS at the time of delivery." This response is appropriate because GBS status can change during pregnancy, and testing closer to the delivery date provides the most up-to-date information. Testing earlier in pregnancy may not accurately reflect the GBS status at the time of delivery.
Choice A is incorrect because the presence of symptoms is not a reliable indicator of GBS status. Choice B is incorrect as past negative GBS results do not guarantee the current status. Choice C is incorrect because GBS screening is typically done later in pregnancy regardless of earlier test results.
A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first?
- A. A client who is at 11 weeks of gestation and reports abdominal cramping
- B. A client who is at 15 weeks of gestation and reports tingling and numbness in right hand
- C. A client who is at 20 weeks of gestation and reports constipation for the past 4 days
- D. A client who is at 8 weeks of gestation and reports having three bloody noses in the past week
Correct Answer: A
Rationale: The correct answer is A: A client who is at 11 weeks of gestation and reports abdominal cramping. Abdominal cramping in early pregnancy can be a sign of ectopic pregnancy, miscarriage, or other complications requiring immediate attention. The nurse should see this client first to assess the situation and provide appropriate interventions.
Choice B is incorrect because tingling and numbness in the right hand is not typically an urgent issue in pregnancy. Choice C is incorrect as constipation, while uncomfortable, is not an immediate concern that requires urgent attention. Choice D is incorrect as bloody noses can be common in pregnancy due to increased blood volume and nasal congestion, but it does not require immediate attention unless severe or persistent.
Which of the following nursing actions should the nurse plan to take? For each potential nursing action, click to specify it the intervention is indicated or contraindicated for the client.
- A. Insert a large bore intravenous catheter.
- B. Assess cervical dilation.
- C. Weigh perineal pads.
- D. Administer methotrexate.
Correct Answer: A, C
Rationale: [1, 0, 1]
The correct answers are A and C (Weigh perineal pads).
- A large bore IV catheter may be necessary for rapid fluid resuscitation in emergencies, indicated for critically ill patients.
- Weighing perineal pads is essential to monitor postpartum bleeding, ensuring accurate assessment and timely intervention.
- Assessing cervical dilation (B) is not typically a nursing action but a medical provider's task during labor.
- Administering methotrexate (D) is a medical intervention for conditions like ectopic pregnancy, not within a nurse's scope.
A nurse is reviewing laboratory findings for a client who is at 20 weeks of gestation. Which of the following findings should the nurse report to the provider?
- A. Hematocrit 37% (37% to 47%)
- B. Creatinine 0.9 mg/dL (0.5 to 1 mg/dL)
- C. WBC count 11,000/mm3 (5,000 to 10,000/mm3)
- D. Fasting blood glucose 180 mg/dL (74 to 106 mg/dL)
Correct Answer: D
Rationale: The correct answer is D: Fasting blood glucose 180 mg/dL (74 to 106 mg/dL). During pregnancy, elevated blood glucose levels can indicate gestational diabetes, which can pose risks to both the mother and the fetus. A fasting blood glucose level of 180 mg/dL is significantly above the normal range of 74 to 106 mg/dL and warrants immediate attention from the healthcare provider to initiate appropriate management and monitoring.
Choice A (Hematocrit 37%): Falls within the normal range for a pregnant woman and does not raise immediate concerns.
Choice B (Creatinine 0.9 mg/dL): Within the normal range and not typically a cause for concern at this level.
Choice C (WBC count 11,000/mm3): Slightly elevated but can be a normal physiological response to pregnancy due to increased blood volume and does not necessarily indicate a problem.
In summary, the other choices do not indicate an urgent issue requiring immediate provider notification
A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?
- A. Substernal retractions
- B. Acrocyanosis
- C. Overlapping suture lines
- D. Head circumference 33 cm (13 in)
Correct Answer: A
Rationale: The correct answer is A: Substernal retractions. Substernal retractions in a newborn indicate respiratory distress and can be a sign of a serious issue such as respiratory distress syndrome. This finding requires immediate attention from the provider to assess and manage the newborn's respiratory status. Acrocyanosis (B) is a common finding in newborns and is not typically concerning. Overlapping suture lines (C) can be normal in newborns due to molding during birth. A head circumference of 33 cm (13 in) (D) falls within the normal range for a newborn and does not require immediate reporting.