Nokea
A woman, who is in pain from a diagnosis of mastitis, has abruptly weaned her baby to a bottle. Her actions place the woman at high risk for which of the following?
- A. Mammary rupture.
- B. Postpartum psychosis.
- C. Supernumerary nipples.
- D. Breast abscess.
Correct Answer: D
Rationale: Abrupt weaning can lead to milk stasis, increasing the risk of a breast abscess due to bacterial infection.
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What is the gravida and para for a patient who delivered triplets 2 years ago and is now pregnant again?
- A. 2, 3
- B. 1, 2
- C. 2, 1
- D. 1, 3
Correct Answer: C
Rationale: The correct answer is C: 2, 1. Gravida refers to the total number of pregnancies, including the current one. The patient delivered triplets 2 years ago, so she is currently pregnant again, making her total pregnancies 2. Para refers to the number of deliveries after 20 weeks of gestation, regardless of the number of fetuses. Since she delivered triplets 2 years ago, she had 1 delivery after 20 weeks of gestation, making her para 1. Choices A, B, and D are incorrect as they do not accurately reflect the patient's obstetric history based on the information provided.
The health care provider reports that the primigravida's fundus can be palpated at the umbilicus. Which priority question will the nurse include in the patient's assessment?
- A. Have you noticed that it is easier for you to breathe now?'
- B. Would you like to hear the baby's heartbeat for the first time?'
- C. Have you felt a fluttering sensation in your lower pelvic area yet?'
- D. Have you recently developed any unusual cravings, such as for chalk or dirt?'
Correct Answer: C
Rationale: The correct answer is C: "Have you felt a fluttering sensation in your lower pelvic area yet?" This is the correct question to ask because feeling a fluttering sensation in the lower pelvic area is indicative of quickening, which typically occurs around 18-20 weeks of pregnancy. Quickening is an important milestone in pregnancy that signifies fetal movement. Palpating the fundus at the umbilicus suggests the pregnancy is around 20 weeks, so asking about quickening confirms fetal viability and normal development.
Choice A is incorrect because fundal height does not correlate with ease of breathing. Choice B is incorrect as hearing the baby's heartbeat for the first time is not directly related to fundal height. Choice D is incorrect as unusual cravings are not typically associated with fundal height assessment.
A 4-day-old breastfeeding neonate, whose birth weight was 2,678 grams, has lost 286 grams since its cesarean birth. Which of the following actions should the nurse take?
- A. Nothing, because this is an acceptable weight loss.
- B. Advise the mother to stop breastfeeding and give formula.
- C. Notify the neonatologist of the excessive weight loss.
- D. Give the baby dextrose water between breast feedings.
Correct Answer: A
Rationale: A weight loss of up to 10% of birth weight in the first week is considered normal for breastfed neonates.
The nurse reports a nonreactive NST to the physician. The physician orders vibroacoustic stimulation. Which does the nurse understand the appropriate application for the vibroacoustic stimulation to be? Select all that apply.
- A. Clap loudly by the fetal head
- B. Apply a sterile drape to abdomen prior to stimulation
- C. Apply the artificial larynx stimulus by the fetal head
- D. Limit the use of the artificial larynx stimulus to three times
Correct Answer: C
Rationale: The correct answer is C: Apply the artificial larynx stimulus by the fetal head. Vibroacoustic stimulation involves using sound waves to stimulate the fetus and provoke a response, particularly in cases of nonreactive nonstress test (NST). By applying the artificial larynx stimulus near the fetal head, the nurse ensures direct and effective stimulation of the fetus. This method has been found to be safe and effective in improving fetal heart rate reactivity.
Incorrect Choices:
A: Clap loudly by the fetal head - This is not an appropriate method for vibroacoustic stimulation as it may not provide the controlled and targeted stimulation needed.
B: Apply a sterile drape to abdomen prior to stimulation - This is not necessary for vibroacoustic stimulation and does not contribute to its effectiveness.
D: Limit the use of the artificial larynx stimulus to three times - There is no specific limit to the number of times vibroacoustic stimulation can be applied, as it depends on the
A nurse is following the PDSA cycle for quality improvement. Which action will the nurse take for the letter “A”?
- A. Act
- B. Alter
- C. Assess
- D. Approach
Correct Answer: A
Rationale: There are many models for quality improvement and performance improvement. One model is the PDSA cycle: plan, do, study, and act.