Nokea
Before taking the newborn's vital signs, the nurse should warm his or her hands and the stethoscope to prevent heat loss resulting from which of the following?
- A. Evaporation.
- B. Conduction.
- C. Radiation.
- D. Convection.
Correct Answer: B
Rationale: Cold surfaces cause conductive heat loss.
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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 has completed a postpartum assessment on a patient who delivered 1 hour ago. Which amount of lochia consists of a moderate amount?
- A. Saturated peripad
- B. 10 to 15 cm (4- to 6-inch) stain on the peripad
- C. 2.5 to 10 cm (1- to 4-inch) stain on the peripad
- D. Less than a 1-inch stain on the peripad
Correct Answer: B
Rationale: The correct answer is B (10 to 15 cm (4- to 6-inch) stain on the peripad) because a moderate amount of lochia typically indicates a blood stain of 10 to 15 cm within 1 hour postpartum. This amount of lochia signifies a normal postpartum bleeding pattern.
Incorrect answers:
A: Saturated peripad indicates a heavy amount of lochia, not moderate.
C: 2.5 to 10 cm (1- to 4-inch) stain on the peripad is considered light, not moderate.
D: Less than a 1-inch stain on the peripad is minimal lochia, not moderate.
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.
A breastfeeding woman has been diagnosed with retained placental fragments 4 days postdelivery. Which of the following breastfeeding complications would the nurse expect to see?
- A. Engorgement.
- B. Mastitis.
- C. Blocked milk duct.
- D. Low milk supply.
Correct Answer: B
Rationale: Retained fragments increase infection risk.
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.