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 because it helps prevent irritation or infection on the baby's delicate skin. Washing the baby's face with plain water is gentle and safe for newborns.
A: Bathing the baby immediately after a feeding is not recommended as it may lead to discomfort or spitting up.
B: Placing a bumper pad in the baby's crib can pose a suffocation hazard for the newborn.
C: Putting a soft mattress in the baby's crib increases the risk of sudden infant death syndrome (SIDS) as it may cause suffocation.
Overall, washing the baby's face with plain water is the safest and most appropriate instruction for home safety with a 2-day postpartum client.
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A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take?
- A. Limit the amount of time the fetus is in the client’s room.
- B. Provide the client with photos of the fetus.
- C. Instruct the client that an autopsy should be performed within 24 hr.
- D. Inform the client that the law requires them to name the fetus.
Correct Answer: B
Rationale: The correct answer is B: Provide the client with photos of the fetus. This action allows the client to have tangible memories of their stillborn child, which can aid in the grieving process and provide closure. Providing photos is a sensitive and compassionate gesture that acknowledges the significance of the loss. It also respects the client's autonomy in choosing how they wish to remember their child.
The other choices are not appropriate in this situation:
A: Limiting the time the fetus is in the room may not consider the emotional needs of the client.
C: Instructing the client about an autopsy may be insensitive and distressing without discussing it first with the client.
D: Informing the client about naming the fetus is not a legal requirement and could add unnecessary pressure during a difficult time.
A nurse is caring for a client who is 1 day postpartum and breastfeeding her newborn. The client reports sore nipples. Which of the following actions should the nurse take?
- A. Instruct the client to wait 4 hr between daytime feedings.
- B. Assess the newborn's latch while breastfeeding.
- C. Have the client limit the length of breastfeeding to 5 min per breast.
- D. Offer supplemental formula between the newborn's feedings.
Correct Answer: B
Rationale: The correct answer is B: Assess the newborn's latch while breastfeeding. Sore nipples in breastfeeding mothers are often caused by improper latch. By assessing the newborn's latch, the nurse can identify any issues and provide guidance to the client on how to improve latch technique, which can alleviate nipple soreness. Waiting 4 hours between feedings (choice A) can lead to engorgement and decreased milk supply. Limiting breastfeeding time to 5 min per breast (choice C) can also affect milk supply. Offering supplemental formula (choice D) can interfere with establishing successful breastfeeding.
A nurse is caring for a client who is at 20 weeks of gestation and has trichomoniasis. Which of the following findings should the nurse expect?
- A. Thick, white vaginal discharge
- B. Urinary frequency
- C. Vulva lesions
- D. Malodorous discharge
Correct Answer: D
Rationale: The correct answer is D: Malodorous discharge. Trichomoniasis is a sexually transmitted infection caused by a parasite, leading to a foul-smelling vaginal discharge. At 20 weeks of gestation, the nurse should expect this symptom due to the infection. Thick, white vaginal discharge (choice A) is more indicative of a yeast infection. Urinary frequency (choice B) is not typically associated with trichomoniasis. Vulva lesions (choice C) are more commonly seen in herpes infection. Therefore, the malodorous discharge (choice D) aligns with the expected finding in a client with trichomoniasis at 20 weeks of gestation.
A nurse is administering a hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?
- A. Administer the injection into the vastus lateralis muscle.
- B. Vigorously massage the site following the injection.
- C. Insert the needle at a 45° angle for injection.
- D. Use a 21-gauge needle for the injection.
Correct Answer: A
Rationale: The correct answer is A: Administer the injection into the vastus lateralis muscle. For newborns, the vastus lateralis muscle is the preferred site for intramuscular injections due to its size and well-developed muscle mass, ensuring proper absorption and minimizing the risk of injury to surrounding structures. Administering the vaccine into this muscle also helps improve vaccine efficacy. Choices B, C, and D are incorrect. Choice B, vigorously massaging the site, can cause discomfort, bruising, and potential tissue damage. Choice C, inserting the needle at a 45° angle, is not recommended for intramuscular injections as the needle should be inserted at a 90° angle to ensure proper delivery into the muscle. Choice D, using a 21-gauge needle, is not specific for newborns and can be too large for their small muscle mass, causing unnecessary pain and potential tissue damage.
A nurse is assessing a newborn whose mother had gestational diabetes mellitus. The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?
- A. Abdominal distention
- B. Petechiae
- C. Increased muscle tone
- D. Jitteriness
Correct Answer: D
Rationale: The correct answer is D: Jitteriness. Neonates born to mothers with gestational diabetes are at risk for hypoglycemia due to the abrupt cessation of the maternal glucose supply postnatally. Jitteriness is a common manifestation of hypoglycemia in newborns. It is important for the nurse to monitor for this sign as it indicates the need for prompt intervention to prevent further complications. Abdominal distention, petechiae, and increased muscle tone are not typically associated with hypoglycemia in newborns born to mothers with gestational diabetes.