Nokea
A postpartum patient asks, “Will these stretch marks ever go away?” Which is the nurse’s best response?
- A. “No, never.”
- B. “Yes, eventually.”
- C. “They will fade to silvery lines but won’t disappear completely.”
- D. “They will continue to fade and should be gone by your 6-week checkup.”
Correct Answer: C
Rationale: The correct answer is C: “They will fade to silvery lines but won’t disappear completely.” This response is the best because it provides a realistic expectation to the patient. Stretch marks may lighten over time but typically do not completely disappear. Choice A is incorrect as it provides a definitive and discouraging answer. Choice B is vague and does not offer a clear timeframe. Choice D is incorrect as it gives an overly optimistic timeline that may not be realistic for most individuals. Overall, choice C is the most accurate and supportive response for the patient's query.
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A woman states that she is going to bottle feed her baby because, 'I hate milk and I know that to make good breast milk I will have to drink milk.' The nurse's response about producing high-quality breast milk should be based on which of the following?
- A. The mother must drink at least 3 glasses of milk per day to absorb sufficient quantities of calcium.
- B. The mother should consume at least 1 glass of milk per day but should also consume other dairy products like cheese.
- C. The mother can consume a variety of good calcium sources like broccoli and fish with bones as well as dairy products.
- D. The mother must monitor her protein intake more than her calcium intake because the baby needs the protein for growth.
Correct Answer: C
Rationale: Diverse dietary sources provide adequate nutrition.
The nurse does not hear the baby swallow when suckling even though the baby appears to be latched properly to the breast. Which of the following situations may be the reason for this observation?
- A. The mother reports a pain level of 4 on a 5-point scale.
- B. The baby has been suckling for over 10 minutes.
- C. The mother uses the cross-cradle hold while feeding.
- D. The baby lies with the chin touching the under part of the breast.
Correct Answer: D
Rationale: Proper latch involves the chin touching the breast for efficient milk transfer.
The nurse is providing care to a patient 2 hours after a cesarean birth. In the hand-off report, he preceding nurse indicated that the patient’s lochia was scant rubra. On initial assessment, the oncoming nurse notes the patient’s peripad is saturated with lochia rubra immediately after breastfeeding her infant. What is the nurse’s priority action with this finding?
- A. Weigh the peripad.
- B. Replace the peripad.
- C. Contact the health care provider.
- D. Document the finding in the patient’s chart.
Correct Answer: C
Rationale: The correct answer is C: Contact the health care provider. This is the priority action because the sudden increase in lochia flow after breastfeeding could indicate postpartum hemorrhage, which is a serious complication that requires immediate medical attention. Contacting the healthcare provider will allow for prompt assessment and intervention.
A: Weigh the peripad - This is not the priority action as assessing the amount of blood loss is important, but contacting the healthcare provider for further assessment and intervention takes precedence.
B: Replace the peripad - While maintaining cleanliness and hygiene is important, addressing the potential postpartum hemorrhage is the priority.
D: Document the finding in the patient’s chart - Documentation is necessary but should come after the immediate concern of postpartum hemorrhage is addressed.
A client who has been diagnosed with deep vein thrombosis has been ordered to receive 12 units heparin/min. The nurse receives a 500-mL bag of D5W with 20,000 units of heparin added from the pharmacy. At what rate in mL/hr should the nurse set the infusion pump? (Calculate to the nearest whole.)
- A. 30
- B. NA
- C. NA
- D. NA
Correct Answer: A
Rationale: Calculation: 12 units × 500 mL ÷ 20,000 units = 30 mL/hr.
A couple has delivered a 28-week fetal demise. Which of the following nursing actions are appropriate to take?Select one that doesn't apply
- A. Swaddle the baby in a baby blanket.
- B. Discuss funeral options for the baby.
- C. Encourage the couple to try to get pregnant again in the near future.
- D. Ask the couple whether they would like to hold the baby.
Correct Answer: C
Rationale: Holding the baby and discussing funeral options support grieving.