Nokea
A nurse is reviewing signs of effective breathing with a client who is 5 days postpartum. Which of the following information should the nurse include in the teaching?
- A. "You should feel a tugging sensation when the baby is sucking.
- B. You should expect your baby to have two to three wet diapers in 24hour period
- C. "Your baby's urine should appear dark and concentrated".
- D. "Your breast should stay firm after the baby breastfeeds".
Correct Answer: B
Rationale: Rationale: Choice B is correct because a newborn should have at least 6-8 wet diapers in a 24-hour period, indicating adequate hydration and effective breastfeeding. This frequency of wet diapers is a sign of adequate milk intake and hydration for the baby, which is crucial for their growth and development. Choices A, C, and D are incorrect because feeling a tugging sensation, dark and concentrated urine, and firm breasts are not indicators of effective breathing or breastfeeding in a newborn.
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The nurse is preparing a client for a scheduled cesarean delivery. What is the priority preoperative instruction?
- A. Eat a high-protein meal before surgery.
- B. Empty your bladder before the procedure.
- C. Avoid brushing your teeth on the morning of surgery.
- D. Refrain from taking prescribed medications.
Correct Answer: B
Rationale: The correct answer is B: Empty your bladder before the procedure. This is the priority preoperative instruction because a full bladder can increase the risk of complications during surgery, such as injury to the bladder or difficulties in catheter insertion. It is essential to ensure the bladder is empty to provide a clear surgical field and prevent urinary retention postoperatively.
Explanation for other choices:
A: Eating a high-protein meal before surgery is not recommended as it can increase the risk of aspiration during anesthesia.
C: Avoiding brushing teeth on the morning of surgery is not a priority instruction. Maintaining oral hygiene is important, but it does not directly impact the surgical procedure.
D: Refraining from taking prescribed medications should be discussed with the healthcare provider, as certain medications may need to be taken even on the day of surgery to prevent complications.
What must instructions for use of nonoxynol-9 spermicide include?
- A. Nononxynol-9 used with barrier methods increases their efficacy.
- B. When spermicide is used with condoms, it will further decrease the risk of STIs.
- C. Remove excess spermicide from the vagina within 6 hours to reduce vaginal irritation.
- D. Place the spermicide close to the opening of the vagina for maximal effectiveness.
Correct Answer: C
Rationale: The correct answer, C, states that excess spermicide should be removed from the vagina within 6 hours to reduce vaginal irritation. This is important as leaving excess spermicide can lead to discomfort and irritation. It is a crucial instruction to ensure the user's comfort and safety.
Choice A is incorrect as nonoxynol-9 does not necessarily increase efficacy when used with barrier methods.
Choice B is incorrect because while using spermicide with condoms can reduce the risk of STIs, the statement does not specifically address the instructions for use.
Choice D is incorrect as placing the spermicide close to the vagina's opening does not guarantee maximal effectiveness and is not a critical instruction for safe use.
A postpartum client is getting ready to receive a Depo-Provera injection. Which statement by the client indicates that further teaching by the nurse is necessary?
- A. You will give this shot just like the rubella injection I received yesterday.
- B. I will watch my weight and try to exercise daily after receiving this injection.
- C. I will need to reschedule a follow-up appointment in 3 months.
- D. It might take me a year to get pregnant after receiving this type of birth control.
Correct Answer: A
Rationale: The correct answer is A because the client's comparison of receiving a Depo-Provera injection to a rubella injection is incorrect. Depo-Provera is a hormonal contraceptive injection that does not have the same administration process or purpose as a rubella vaccination. This indicates a lack of understanding about the medication.
Choice B is not the correct answer because it shows the client's awareness of the importance of weight management and exercise in conjunction with receiving the injection.
Choice C is not the correct answer because it demonstrates the client's understanding of the need for a follow-up appointment in 3 months which is necessary for monitoring and continuation of the contraceptive method.
Choice D is not the correct answer because it shows the client's understanding of the potential delay in fertility after discontinuing Depo-Provera, which is an important aspect of the contraceptive method that the client should be aware of.
Upon delivery of the newborn, the nursing intervention that most promotes parental attachment is:
- A. Placing the infant under the radiant warmer
- B. Allowing the mother to rest immediately after delivery
- C. Placing the newborn on mother's chest and abdomen
- D. Taking the newborn to the nursery for the initial assessment
Correct Answer: C
Rationale: The correct answer is C: Placing the newborn on mother's chest and abdomen. This promotes parental attachment through skin-to-skin contact, facilitating bonding and emotional connection. It also helps regulate the baby's temperature and encourage breastfeeding. Placing the infant under the radiant warmer (A) may disrupt immediate bonding. Allowing the mother to rest (B) is important, but promoting attachment should be prioritized. Taking the newborn to the nursery (D) can delay the crucial bonding process.
During the assessment of a newborn, it is most important for the nurse to report a:
- A. Temperature of 97.7 degrees Fahrenheit
- B. Pale pink, rust-colored stain in the diaper
- C. Heart rate that drops to 120 beats/min
- D. Breathing pattern that is diaphragmatic with sternal retractions
Correct Answer: D
Rationale: The correct answer is D because a breathing pattern that is diaphragmatic with sternal retractions indicates respiratory distress in a newborn, which is a critical condition requiring immediate attention. Staying logical, let's assess the other choices:
A: Temperature of 97.7 degrees Fahrenheit is within the normal range for a newborn and does not indicate an urgent issue.
B: A pale pink, rust-colored stain in the diaper could be due to various factors such as diet and is not an immediate concern.
C: A heart rate dropping to 120 beats/min in a newborn is generally within the normal range and does not signify a critical issue.