Nokea
A rubella nonimmune, breastfeeding client has just received the rubella vaccine. Which of the following side effects should the nurse warn the client about?
- A. The baby may develop a rash a week after the shot.
- B. The baby may temporarily reject the breast milk.
- C. The mother's milk supply may decrease precipitously.
- D. The mother's joints may become painful and stiff.
Correct Answer: D
Rationale: Rubella vaccine may cause joint pain as a side effect.
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The home health nurse is visiting a client with HIV who is 6 weeks postdelivery. Which of the following findings would indicate that patient teaching by the nurse in the hospital was successful?
- A. The client is breastfeeding her baby every two hours.
- B. The client is using a diaphragm for family planning.
- C. The client is taking her temperature every morning.
- D. The client is seeking care for a recent weight loss.
Correct Answer: D
Rationale: Weight loss may indicate opportunistic infection.
A postpartum woman has been diagnosed with postpartum psychosis. Which of the following is essential to be included in the family teaching for this client?
- A. The woman should never be left alone with her infant.
- B. Symptoms rarely last more than one week.
- C. Clinical response to medications is usually poor.
- D. The woman must have her vitals assessed every two days.
Correct Answer: A
Rationale: Safety is paramount with psychosis.
A mother calls the nurse to her room because 'My baby's eyes are bleeding.' The nurse notes bright red hemorrhages in the sclerae of both of the baby's eyes. Which of the following actions by the nurse is appropriate at this time?
- A. Notify the pediatrician immediately and report the finding.
- B. Notify the social worker about the probable maternal abuse.
- C. Reassure the mother that the trauma resulted from pressure changes at birth and the hemorrhages will slowly disappear.
- D. Obtain an ophthalmoscope from the nursery to evaluate the red reflex and condition of the retina in each eye.
Correct Answer: C
Rationale: Subconjunctival hemorrhages are common and resolve spontaneously.
A woman is receiving Paxil (paroxetine) for postpartum depression. To prevent a drug/food interaction, the client must be advised to refrain from consuming which of the following?
- A. Alcohol.
- B. Grapefruit.
- C. Milk.
- D. Cabbage.
Correct Answer: B
Rationale: Grapefruit affects drug metabolism.
Which of the following are nursing measures that can promote parent-infant bonding and attachment? (Select all that apply.)
- A. Provide comfort and ample time for rest.
- B. Keep the baby wrapped to avoid cold stress.
- C. Position the infant face to face with the mother.
- D. Point out the characteristics of the infant in a positive way.
Correct Answer: A
Rationale: Rationale:
A: Providing comfort and ample time for rest helps parents feel less stressed, promoting bonding.
B: Keeping the baby wrapped is important for warmth but does not directly impact bonding.
C: Positioning face to face can enhance bonding, but it is not a nursing measure.
D: Pointing out characteristics positively can boost parent's confidence but does not directly promote bonding.