Nokea
A primiparous client who will be bottle-feeding her neonate asks, "What is the best position for the baby after feeding?" Which of the following positions should the nurse recommend to aid digestion?
- A. Supine position.
- B. On the left side.
- C. Prone with the infant's head elevated on a pillow.
- D. Sitting on the caregiver's lap for 20 minutes.
Correct Answer: D
Rationale: Sitting upright after feeding aids digestion by allowing gravity to keep formula in the stomach.
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A nurse is counseling a client about the fertility awareness method. Which of the following client statements indicates a need for further teaching?
- A. I will track my basal body temperature daily.
- B. I will monitor my cervical mucus for changes.
- C. I will avoid intercourse during my fertile days.
- D. I can rely on this method even with irregular cycles.
Correct Answer: D
Rationale: The fertility awareness method is less reliable with irregular cycles, as ovulation is harder to predict. The other statements reflect correct understanding, indicating a need for further teaching about cycle regularity.
The nurse is to draw a blood sample for glucose testing from a term neonate during the first hour after birth. The nurse should obtain the blood sample from the neonate's foot near which of the following areas?
Correct Answer: B
Rationale: The blood sample should be obtained from the lateral or medial heel of the neonate's foot to minimize pain and avoid major nerves and blood vessels.
The physician determines that the fetus of a multiparous client in active labor is in distress, necessitating a cesarean delivery with general anesthesia. Before the cesarean delivery, the anesthesiologist orders cimetidine (Tagamet) 300 mg PO. After administering the drug, the nurse should assess the client for reduction in which of the following?
- A. Incidence of bronchospasm.
- B. Oral and respiratory secretions.
- C. Acid level of the stomach contents.
- D. Incidence of postoperative gastric ulcer.
Correct Answer: C
Rationale: Cimetidine, an H2-receptor blocker, is given before general anesthesia to reduce gastric acid levels, minimizing the risk of aspiration pneumonitis. It does not affect bronchospasm, secretions, or postoperative ulcers directly.
When assessing the frequency of contractions of a multiparous client in active labor admitted to the birthing area, the nurse should assess the interval between which of the following?
- A. Acme of one contraction to the beginning of the next contraction.
- B. Beginning of one contraction to the end of the next contraction.
- C. End of one contraction to the end of the next contraction.
- D. Beginning of one contraction to the beginning of the next contraction.
Correct Answer: D
Rationale: Contraction frequency is measured from the beginning of one contraction to the beginning of the next, capturing the full cycle and rest period, which is critical for assessing labor progress.
In response to the nurse's question about how she is feeling, a postpartum client states that she is fine. She then begins talking to the baby, checking the diaper, and asking infant care questions. The nurse determines the client is in which postpartal phase of psychological adaptation?
- A. Taking in.
- B. Taking on.
- C. Taking hold.
- D. Letting go.
Correct Answer: C
Rationale: The 'taking hold' phase is characterized by the mother becoming more active, showing interest in caring for the infant, and asking questions about infant care, as described in the scenario.