Nokea
A woman who wishes to breastfeed advises the nurse that she has had breast augmentation surgery. Which of the following responses by the nurse is appropriate?
- A. Breast implants often contaminate the milk with toxins.
- B. The glandular tissue of women who need implants is often deficient.
- C. Babies often have difficulty latching to the nipples of women with breast implants.
- D. Women who have implants are often able exclusively to breastfeed.
Correct Answer: D
Rationale: Implants do not preclude breastfeeding.
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The nurse is evaluating the effectiveness of an intervention when assisting a woman whose baby has been latched to the nipple only rather than to the nipple and the areola. Which response would indicate that further intervention is needed?
- A. The client states that the pain has decreased.
- B. The nurse hears the baby swallow after each suck.
- C. The baby's jaws move up and down once every second.
- D. The baby's cheeks move in and out with each suck.
Correct Answer: C
Rationale: Rapid jaw movements without swallowing suggest ineffective feeding.
The nurse assesses for signs of depression or postpartum blues. How can the nurse explain the difference?
- A. PPD is less severe and resolves in a few weeks.
- B. Postpartum blues can last up to a year.
- C. PPD is a normal expectation of postpartum.
- D. Postpartum blues symptoms include irritability and sadness.
Correct Answer: D
Rationale: The correct answer is D because postpartum blues typically involve symptoms like irritability and sadness, which are common and usually resolve within a few weeks. This is different from postpartum depression (PPD), which is more severe and may last longer. A is incorrect because PPD is typically more severe than postpartum blues. B is incorrect because postpartum blues usually resolve within a few weeks, not up to a year. C is incorrect because PPD is not considered a normal expectation of postpartum, as it requires intervention and treatment.
A client is receiving an IV heparin drip at 16 mL/hr via an infusion pump for a diagnosis of deep vein thrombosis. The label on the 1/2 liter bag of D5W indicates 25,000 units of heparin have been added. How many units of heparin is the client receiving per hour? (Calculate to the nearest whole.)
- A. 800
- B. NA
- C. NA
- D. NA
Correct Answer: A
Rationale: Calculation: 25,000 units ÷ 500 mL × 16 mL = 800 units.
A client, 1 day postpartum (PP), is being monitored carefully after a significant postpartum hemorrhage. Which of the following should the nurse report to the obstetrician?
- A. Urine output 200 mL for the past 8 hours.
- B. Weight decrease of 2 pounds since delivery.
- C. Drop in hematocrit of 2% since admission.
- D. Pulse rate of 68 beats per minute.
Correct Answer: A
Rationale: Reduced urine output indicates potential hypovolemia.
A client is 3 days post-cesarean delivery for eclampsia. The client is receiving hydralazine (Apresoline) 10 mg 4 times a day by mouth. Which of the following findings would indicate that the medication is effective?
- A. The client has had no seizures since delivery.
- B. The client's blood pressure has dropped from 160/120 to 130/90.
- C. The client's postoperative weight has dropped from 154 to 144 lb.
- D. The client states that her headache is gone.
Correct Answer: B
Rationale: Hydralazine lowers blood pressure.