Nokea
The best indication that correct attachment to the breast has occurred is when the:
- A. Baby's tongue is securely on top of the nipple.
- B. Baby's mouth covers most of the areolar surface
- C. Baby makes frequent loud clucking sounds while nursing at each breast d, Baby sucks each breast vigorously for five minutes before falling asleep
Correct Answer: B
Rationale: The best indication that correct attachment to the breast has occurred is when the baby's mouth covers most of the areolar surface. This is important because proper latch and attachment are crucial for effective breastfeeding. When the baby's mouth covers most of the areola, it ensures that the baby is latched onto the breast properly, allowing them to feed efficiently and receive an adequate amount of milk. This also helps prevent nipple soreness and pain for the mother. Additionally, when the baby's mouth covers most of the areola, it helps ensure that the baby is positioned correctly to effectively stimulate milk production and flow.
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A new mother asks the nurse why newborns receive an injection of vit. K after delivery. What will be the best response from the nurse?
- A. Newborns are given vit K to help with the digestion to help them absorb fat soluble vitamins
- B. Newborns are given vit K and erythromycin ointment to help prevent ophthalmia neonatorum
- C. Newborns lack the intestinal flora needed to produce vit K, so it is given to prevent bleeding episodes
- D. This vitamin substitutes for vitamin C and newborns will strengthen their immune system
Correct Answer: C
Rationale: Vitamin K is essential for clotting and prevents hemorrhagic disease.
A pregnant woman is to undergo an invasive procedure to evaluate the status of her fetus. To ensure informed consent, which action would be the priority responsibility of the nurse providing care to this woman?
- A. Asking relevant questions to determine the client's understanding
- B. Providing a detailed description of the risks and benefits of the procedure
- C. Explaining the exact steps that will occur during the procedure
- D. Offering suggestions for alternative options for treatment
Correct Answer: A
Rationale: The nurse's responsibilities related to informed consent include: Ensuring the consent form is completed with signatures from the client; serving as a witness to the signature process; and determining whether the client understands what she is signing by asking her pertinent questions.
The nurse is reviewing a copy of the U.S. Surgeon General's Report, Healthy People 2020. Which nursing action best reflects the nurse fostering this health care agenda?
- A. The nurse signs up for classes to obtain an advanced degree in nursing.
- B. The nurse volunteers at a local health care clinic providing free vaccinations for low-income populations.
- C. The nurse performs an in-service on basic hospital equipment for student nurses.
- D. The nurse compiles nursing articles on evidence-based practices in nursing to present at a hospital training seminar.
Correct Answer: B
Rationale: Healthy People 2020 is a comprehensive health promotion and disease prevention agenda that is working toward improving the quantity and quality of life for all Americans.
What nursing intervention is appropriate for a woman diagnosed with syphilis?
- A. Council the woman about how to live with a chronic infection.
- B. Question the woman regarding symptoms of other sexually transmitted infections.
- C. Assist the primary health care practitioner with cryotherapy procedures.
- D. Educate the woman regarding the safe disposal of menstrual pads.
Correct Answer: B
Rationale: Syphilis often coexists with other STIs, so questioning is important.
During the first few minutes after birth which physiologic changes occurs in the newborn as response to vascular pressure changes in increased oxygen levels?
- A. Dilation of pulmonary vessel (dilation of pulmonary vessels occurs in response to increased oxygen levels)
Correct Answer: A
Rationale: Immediately after birth, as the newborn takes its first breaths and transitions to breathing air, there is a rapid increase in oxygen levels in the blood. This sudden increase in oxygen causes the pulmonary vessels in the newborn's lungs to dilate. This dilation helps improve blood flow through the lungs, allowing for efficient exchange of oxygen and carbon dioxide. The dilation of pulmonary vessels is a normal physiologic response to the changing environment in the newborn's body after birth.