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The home health nurse visits a client who delivered a full-term baby three days ago. The mother reports that the infant is waking up every 2 hours to bottle feed. The nurse notes white, curl-like patches on the newborns oral mucous membranes. What action should the nurse implement?
- A. Discuss the need for medication to treat curl-like oral patches
- B. Suggest switching the infant's formula
- C. Assess the baby's blood glucose level
- D. Remind mother not put the baby to bed with a propped bottle
Correct Answer: A
Rationale: White patches suggest thrush, which requires antifungal treatment (A).
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Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching on the gravid client?
- A. The client's readiness to learn
- B. The client's educational background
- C. The order in which the information is presented
- D. The extent to which the pregnancy was planned
Correct Answer: A
Rationale: When teaching any client, readiness to learn (A) is the most important criterion. For example, the client with severe morning sickness in the first trimester may not be 'ready to learn' about ways to relieve morning sickness.
The nurse is caring for a newborn who is 18 inches long, weighs 4 pounds, 14 ounces, has a head circumference of 13 inches, and a chest circumference of 10 inches. Based on these physical findings, assessment for which condition has the highest priority?
- A. Hyperthermia
- B. Hyperbilirubinemia
- C. Polycythemia
- D. Hypoglycemia
Correct Answer: D
Rationale: Small-for-gestational-age infants are at high risk for hypoglycemia (D).
Which patient has correctly increased her caloric intake from her recommended pregnancy intake to the amount necessary to sustain breastfeeding in the first 6 postpartum months?
- A. From 1800 to 2200 calories per day
- B. From 2000 to 2500 calories per day
- C. From 2200 to 2530 calories per day
- D. From 2500 to 2730 calories per day
Correct Answer: C
Rationale: Rationale: The correct answer is C because for breastfeeding, an additional 500 calories/day are needed compared to pregnancy. The recommended caloric intake during pregnancy is around 2200 calories/day. Therefore, increasing from 2200 to 2530 calories/day aligns with the additional 500 calories necessary for sustaining breastfeeding.
Summary:
A: Going from 1800 to 2200 calories/day does not provide the extra 500 calories needed for breastfeeding.
B: Increasing from 2000 to 2500 calories/day does not account for the original pregnancy intake or the additional calories required for breastfeeding.
D: Jumping from 2500 to 2730 calories/day exceeds the additional 500 calories needed for breastfeeding, potentially leading to excessive weight gain.
A client at 38-weeks gestation is admitted to the labor and delivery unit with mild contractions every 5 minutes. The client's cervix is dilated 2 cm, 50% effaced, and the fetus is at 0 station. The client's membranes rupture spontaneously, and the fluid is clear. What action should the nurse take next?
- A. Monitor the fetal heart rate pattern.
- B. Perform a vaginal examination.
- C. Encourage the client to ambulate.
- D. Administer pain medication.
Correct Answer: A
Rationale: Monitoring the fetal heart rate pattern after membrane rupture is essential to detect any changes in fetal status.
The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement?
- A. Insert an internal fetal monitor
- B. Assess for cervical changes q1h
- C. Monitor bleeding from IV sites
- D. Perform Leopold's maneuvers
Correct Answer: C
Rationale: Monitoring bleeding from peripheral sites (C) is the priority intervention. This client is presenting with signs of placental abruption. Disseminated intravascular coagulation (DIC) is a complication of placental abruption, characterized by abnormal bleeding.