Nokea
After the nurse teaches a primiparous client planning to return to work in 6 weeks about storing breast milk, which of the following client statements indicates the need for further teaching?
- A. I can let the milk sit out in a bottle for up to 10 hours.
- B. I'll be sure to label the milk with the date, time, and amount.
- C. I can store the milk for 3 days in the refrigerator.
- D. I can keep the milk in a deep-freeze in clean glass bottles for up to 1 year.
Correct Answer: A
Rationale: Breast milk should not be left out for more than 4-6 hours; 10 hours risks spoilage.
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The nurse observes a bottle-feeding multiparous client tilting the bottle so the nipple is partially filled with air. The nurse should:
- A. Instruct the client to tilt the bottle to fill the nipple with formula.
- B. Suggest switching to a different nipple size.
- C. Encourage burping the neonate more frequently.
- D. Document the observation as normal.
Correct Answer: A
Rationale: Tilting the bottle to fill the nipple prevents air swallowing, reducing the risk of gas and regurgitation.
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.
While the nurse is caring for a multiparous client in active labor at 36 weeks' gestation, the client tells the nurse, 'I think my water just broke.' Which of the following should the nurse do first?
- A. Turn the client to the right side.
- B. Assess the color, amount, and odor of the fluid.
- C. Assess the fetal heart rate pattern.
- D. Check the client's cervical dilation.
Correct Answer: C
Rationale: Rupture of membranes can affect fetal well-being, particularly in preterm labor (36 weeks). Assessing the fetal heart rate pattern first ensures the fetus is not in distress (e.g., due to cord compression). Fluid characteristics and dilation are assessed next.
A primigravid client at 41 weeks' gestation is admitted to the hospital's labor and delivery unit in active labor. After 25 hours of labor with membranes ruptured for 24 hours, the client delivers a healthy neonate vaginally with a midline episiotomy. Which of the following nursing diagnoses should the nurse identify as the priority for the client?
- A. Activity intolerance related to difficult labor process.
- B. Sleep deprivation related to prolonged labor.
- C. Situational low self-esteem related to lengthy labor process.
- D. Risk for infection related to birth trauma and prolonged ruptured membranes.
Correct Answer: D
Rationale: Prolonged rupture of membranes (>24 hours) and episiotomy increase infection risk, making this the priority post-delivery. Activity intolerance, sleep deprivation, and self-esteem are less urgent.
A client is considering the withdrawal method. Which of the following statements by the nurse is accurate?
- A. The withdrawal method is highly effective with perfect use.
- B. The withdrawal method has a high failure rate and does not protect against STIs.
- C. The withdrawal method requires a prescription.
- D. The withdrawal method is more effective than oral contraceptives.
Correct Answer: B
Rationale: The withdrawal method has a high failure rate due to pre-ejaculate and timing issues and does not protect against STIs. It does not require a prescription and is less effective than oral contraceptives.