Nokea
The client is being taught about perineal care postpartum. Which instruction should the client receive?
- A. Use ice packs to reduce swelling for the first 24 hours.
- B. Apply heat packs immediately after birth to reduce pain.
- C. Avoid using a peri-bottle to cleanse the perineum.
- D. Use tampons to absorb lochia discharge.
Correct Answer: A
Rationale: The correct instruction for the client postpartum is to use ice packs to reduce swelling for the first 24 hours. This helps alleviate discomfort and promote healing. Applying heat packs immediately after birth is not recommended as they can increase swelling. A peri-bottle is advised for cleansing the perineum, not to be avoided. Tampons should not be used to absorb lochia discharge as they can increase the risk of infection. Therefore, the use of ice packs is the most appropriate and beneficial instruction for perineal care postpartum.
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Warning signs that indicate dehydration include all EXCEPT:
- A. Poor skin turgor
- B. Increased urine output
- C. Tachycardia
- D. Eager to drink
Correct Answer: B
Rationale: The correct answer is B. Increased urine output is not a warning sign of dehydration; it typically decreases with dehydration. Dehydration often presents with poor skin turgor, tachycardia, and an increased sensation of thirst (eager to drink) as the body tries to compensate for fluid loss. Choices A, C, and D are all correct warning signs of dehydration. Poor skin turgor is a result of decreased skin elasticity due to fluid loss. Tachycardia, an elevated heart rate, can be a compensatory mechanism to maintain cardiac output in dehydration. Feeling eager to drink is a common symptom of dehydration as the body attempts to restore fluid balance.
Are most children with hypertension asymptomatic?
- A. TRUE
- B. FALSE
Correct Answer: A
Rationale: The statement is true. In many cases, children with hypertension do not show any symptoms, making it challenging to diagnose them. Regular blood pressure checks are crucial to detect hypertension early, as it can have serious health implications if left untreated. Choice B is incorrect because most children with hypertension do not exhibit symptoms, hence being asymptomatic. Choices C and D are empty as they do not provide additional options.
What is the most appropriate action to prevent heat loss in a newborn immediately after birth?
- A. Place the newborn in an incubator
- B. Bathe the newborn right away
- C. Dry the newborn thoroughly
- D. Feed the newborn
Correct Answer: C
Rationale: Drying the newborn thoroughly is the most appropriate action to prevent heat loss immediately after birth. This helps to prevent heat loss through evaporation, which is crucial in maintaining the newborn's body temperature. Placing the newborn in an incubator can be a secondary step after ensuring the baby is dry. Bathing the newborn right away is not recommended as it can lead to further heat loss through evaporation. Feeding the newborn is important but not an immediate action to prevent heat loss; ensuring the baby is dry and warm takes precedence.
What intervention should the nurse encourage for a postpartum client complaining of perineal pain?
- A. Use of ice packs for the first 24 hours
- B. Application of heat packs immediately
- C. Avoiding the use of peri-bottles
- D. Using tampons to manage lochia
Correct Answer: A
Rationale: The correct intervention for perineal pain in a postpartum client is the use of ice packs for the first 24 hours. Ice packs help reduce swelling and discomfort in the perineal area, especially during the initial post-delivery period. Applying heat packs can exacerbate swelling and discomfort. Avoiding peri-bottles may lead to poor perineal hygiene. Using tampons is contraindicated postpartum as it increases the risk of infection.
A new mother asks the nurse when she should begin to breastfeed her newborn. The nurse's best response is:
- A. Within the first half-hour after birth
- B. After the newborn's first bath
- C. When the newborn begins to cry
- D. After administering vitamin K
Correct Answer: A
Rationale: Initiating breastfeeding within the first half-hour after birth is crucial for successful breastfeeding and bonding, as recommended by the World Health Organization. This early initiation helps establish breastfeeding and supports the newborn's health by providing colostrum, the nutrient-rich first milk. Choice B, 'After the newborn's first bath,' is incorrect because initiating breastfeeding should not be delayed after birth. Choice C, 'When the newborn begins to cry,' is incorrect as it does not promote timely initiation of breastfeeding. Choice D, 'After administering vitamin K,' is incorrect because breastfeeding initiation should not be delayed for this procedure.