Nokea
A primiparous client is on a regular diet 24 hours postpartum. She is from Guatemala and speaks little English. The client's mother asks the nurse if she can bring her daughter some "special foods from home." The nurse responds, based on the understanding about which of the following?
- A. Foods from home are generally discouraged on the postpartum unit.
- B. The mother can bring the daughter any foods that she desires.
- C. This is permissible as long as the foods are nutritious and high in iron.
- D. The client's physician needs to give permission for the foods.
Correct Answer: C
Rationale: Nutritious, iron-rich foods support postpartum recovery and respect cultural preferences.
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A multiparous client delivers dizygotic twins at 37 weeks' gestation. The twin neonates require additional hospitalization after the client is discharged. In planning the family's care, an appropriate goal for the nurse to formulate is that, while the twins are hospitalized, the parents will do which of the following?
- A. Discuss how they will cope with twin infants at home.
- B. Participate in care of the twins as much as possible.
- C. Take turns providing 24-hour observation of the twins.
- D. Identify complications that may occur as the twins develop.
Correct Answer: B
Rationale: Parental participation in twin care during hospitalization promotes bonding, confidence, and skill development. Discussing coping, 24-hour observation, or identifying complications are less immediate or unrealistic.
After circumcision with a Plastibell, the nurse should instruct the neonate's mother to cleanse the circumcision site with which of the following?
- A. Warm water.
- B. Povidone-iodine (Betadine) solution.
- C. Diluted hydrogen peroxide.
Correct Answer: A
Rationale: Warm water is recommended for cleansing the circumcision site to keep it clean and promote healing without causing irritation.
After teaching a multiparous client about the effects of hemolysis due to Rh sensitization on the neonate at delivery, the nurse determines that the client needs further instruction when the mother reports that the neonate may have which of the following?
- A. Cardiac decompensation.
- B. Polycythemia.
- C. Splenomegaly.
- D. Reduced bilirubin levels.
Correct Answer: D
Rationale: Hemolysis due to Rh sensitization causes increased bilirubin levels, not reduced levels, indicating a need for further instruction.
Which of the following best identifies the reason for assessing a neonate weighing 1,500 g at 32 weeks' gestation for retinopathy of prematurity (ROP)?
- A. The neonate is at risk because of multiple factors.
- B. Oxygen is being administered at a level of $21%.
- C. The neonate was alkalotic immediately after birth.
- D. Phototherapy is likely to be ordered by the pediatrician.
Correct Answer: A
Rationale: Preterm neonates, especially those with low birth weight and receiving oxygen, are at risk for ROP due to immature retinal development.
During a home visit to a breast-feeding primiparous client at 1 week postpartum, the client tells the nurse that her nipples have become sore and cracked from the feedings. Which of the following should the nurse instruct the client to do?
- A. Wipe off any lanolin creams from the nipple before each feeding.
- B. Position the baby with the entire areola in the baby's mouth.
- C. Feed the baby less often for the next several days.
- D. Use a mild soap while in the shower to prevent an infection.
Correct Answer: B
Rationale: Proper positioning with the areola in the baby's mouth prevents and heals sore nipples.