Nokea
A woman states that all of a sudden her 4-day-old baby is having trouble feeding. On assessment, the nurse notes that the mother's breasts are firm, red, and warm to the touch. The nurse teaches the mother manually to express a small amount of breast milk from each breast. Which observation indicates that the nurse's intervention has been successful?
- A. The mother's nipples are soft to the touch.
- B. The baby swallows after every 5th suck.
- C. The baby's pre- and postfeed weight change is 20 milliliters.
- D. The mother squeezes her nipples during manual expression.
Correct Answer: B
Rationale: Effective sucking indicates improved feeding.
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The nurse is about to elicit the Moro reflex. Which of the following responses should the nurse expect to see?
- A. When the cheek of the baby is touched
- B. the newborn turns toward the side that is touched.
- C. When the lateral aspect of the sole of the baby's foot is stroked
- D. the toes extend and fan outward.
Correct Answer: C
Rationale: Moro reflex involves extension of arms and flexion of knees in response to a sudden stimulus.
A nurse is advising a mother of a neonate being discharged from the hospital regarding car seat safety. Which of the following should be included in the teaching plan? Select all that apply.
- A. Place the baby's car seat in the front passenger seat.
- B. Position the car seat rear facing until the baby reaches two years of age.
- C. Attach the car seat to the car at 2 latch points at the base of the car seat.
- D. Check that the installed car seat moves no more than 1 inch side to side or front to back.
Correct Answer: B
Rationale: Rear-facing positioning and secure installation are critical for safety.
A client is to receive a blood transfusion after significant blood loss following a placenta previa delivery. Which of the following actions by the nurse is critical prior to starting the infusion? Select all that apply.
- A. Look up the client's blood type in the chart.
- B. Check the client's arm bracelet.
- C. Check the blood type on the infusion bag.
- D. Obtain an infusion bag of dextrose and water.
Correct Answer: B
Rationale: Blood type verification is critical.
A couple, accompanied by their 5-year-old daughter, have been notified that their 32-week-gestation fetus is dead. The father is yelling at the staff. The mother is crying uncontrollably. The 5-year-old is banging the head of her doll on the floor. Which of the following nursing actions is appropriate at this time?
- A. Tell the father that his behavior is inappropriate.
- B. Sit with the family and quietly communicate sorrow at their loss.
- C. Help the couple to understand that their daughter is acting inappropriately.
- D. Encourage the couple to send their daughter to her grandparents.
Correct Answer: B
Rationale: Supportive presence is key.
The nurse educates the non–breast-feeding person on breast discomfort caused by engorgement. What instructions would they give?
- A. Massage breasts to release milk.
- B. Apply cold packs and cabbage leaves.
- C. Stand in the warm shower to stimulate letdown.
- D. Do not wear a bra.
Correct Answer: B
Rationale: The correct answer is B: Apply cold packs and cabbage leaves. Engorgement causes breast swelling and discomfort due to increased blood and milk supply. Applying cold packs reduces inflammation and pain. Cabbage leaves have a cooling effect and can help reduce swelling. Massaging breasts can worsen engorgement by stimulating more milk production. Standing in a warm shower may provide temporary relief but does not address the root cause. Not wearing a bra may lead to discomfort and does not alleviate engorgement.