Nokea
After instructing a primiparous client who is bottle-feeding about burping, which of the following client statements indicates that the client needs further teaching?
- A. I'll burp him after 15 minutes of feeding him formula.
- B. After he takes one-half ounce of formula, I'll burp him.
- C. I'll burp him while he is in an upright position.
- D. I'll gently pat his back to get him to burp.
Correct Answer: B
Rationale: Burping after one-half ounce is too frequent and may disrupt feeding; burping every 1-2 ounces is more appropriate.
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A primiparous client who delivered vaginally 8 hours ago desires to take a shower. The nurse anticipates remaining nearby the client to assess for which of the following?
- A. Fatigue.
- B. Fainting.
- C. Diuresis.
- D. Hygiene needs.
Correct Answer: B
Rationale: Fainting is a risk during the first shower postpartum due to potential orthostatic hypotension or fatigue, requiring close monitoring.
A primigravid client at 37 weeks' gestation has been hospitalized for several days with severe pregnancy-induced hypertension. While caring for the client, the nurse observes that the client is beginning to have a seizure. Which of the following actions should the nurse do first?
- A. Pad the side rails of the client's bed.
- B. Turn the client to the right side.
- C. Insert a padded tongue blade into the client's mouth.
- D. Call for immediate assistance in the client's room.
Correct Answer: D
Rationale: A seizure in pregnancy-induced hypertension (eclampsia) is a medical emergency. Calling for immediate assistance ensures rapid intervention (e.g., magnesium sulfate). Padding rails, repositioning, or inserting a tongue blade (which is outdated) are secondary.
A client with gestational diabetes who is entering her third trimester is learning how to monitor her fetus's movements. After teaching the client about the kick count, the nurse should provide further instruction if the client makes which of the following statements?
- A. "The baby may be more active at different times of the day."
- B. "How I feel my baby move is different than my friend."
- C. "The baby should be moving less than 10 times in 3 hours."
- D. "The baby may not move at times because it is asleep."
Correct Answer: C
Rationale: The baby should move at least 10 times in 2 hours.
The nurse is caring for a neonate shortly after birth when the neonate is diagnosed with sepsis and is to be treated with intravenous antibiotics. Which of the following should the nurse instruct the parents to do because of the neonate's infection?
- A. Use caution near the isolation incubator and equipment.
- B. Visit but do not touch the neonate.
- C. Wash their hands thoroughly before touching the neonate.
- D. Wear a mask when holding the neonate.
Correct Answer: C
Rationale: Thorough hand washing is critical to prevent further infection in a neonate with sepsis.
The nurse is assessing a client at her postpartum checkup 6 weeks after a vaginal delivery. The mother is bottle feeding her baby. Which client finding indicates a problem at this time?
- A. Firm fundus at the symphysis.
- B. White, thick vaginal discharge.
- C. Striae that are silver in color.
- D. Soft breasts without milk.
Correct Answer: B
Rationale: White, thick vaginal discharge at 6 weeks suggests an infection, as lochia should be minimal or absent by this time.