Nokea
The nurse is aware that a pre-term neonate may have a potential nutritional problem because of:
- A. Poor sucking reflex
- B. A decreased metabolic rate
- C. Decreased caloric requirement
- D. Increased absorption of nutrients
Correct Answer: A
Rationale: The correct answer is A: Poor sucking reflex. Pre-term neonates often have immature sucking reflexes, which can lead to difficulty in feeding and obtaining adequate nutrition. This can result in a potential nutritional problem. Option B is incorrect because pre-term neonates actually have an increased metabolic rate to support their growth and development. Option C is incorrect as pre-term neonates have increased caloric requirements due to their rapid growth. Option D is incorrect as pre-term neonates typically have decreased absorption of nutrients due to an immature gastrointestinal system.
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Which statement by the client would alert the nurse that she should not take oral contraceptives?
- A. I drink one to two alcohol drinks a few times a week.
- B. I am slightly overweight and have a difficult time fitting exercise into my schedule.
- C. I am trying to limit cigarettes to one pack a week.
- D. I try to have my boyfriend wear a condom every time we have sex.
Correct Answer: C
Rationale: The correct answer is C because smoking while taking oral contraceptives increases the risk of blood clots, stroke, and heart attack. Smoking and oral contraceptives together pose a higher risk than either alone. Choices A, B, and D are not direct contraindications for taking oral contraceptives. A: Moderate alcohol consumption is generally not contraindicated. B: Being slightly overweight and having difficulty with exercise are not absolute contraindications. D: Using condoms is a good practice but does not specifically indicate a reason not to take oral contraceptives.
A nurse is assessing a client who is 3 days postpartum and is breastfeeding. The nurse notes that the fundus is three fingerbreadths below the umbilicus, lochia rubra is moderate, and the breasts are hard and warm to palpation. Which of the following interpretations of these findings should the nurse make?
- A. The client is exhibiting early indications of mastitis.
- B. Additional interventions are not indicated at this time.
- C. Application of a heating pad to the breasts is indicated.
- D. The client should be advised to remove her nursing bra.
Correct Answer: B
Rationale: Correct Answer: B - Additional interventions are not indicated at this time.
Rationale:
1. Fundus location: Three fingerbreadths below the umbilicus is within normal range for 3 days postpartum.
2. Lochia rubra: Moderate lochia rubra is expected at this stage postpartum.
3. Breasts: Hard and warm breasts are indicative of engorgement, a common issue in breastfeeding mothers.
Summary:
A: Early indications of mastitis would include redness, warmth, and tenderness in the breasts, along with flu-like symptoms.
C: Application of a heating pad to the breasts can worsen engorgement and increase the risk of mastitis.
D: Removing a nursing bra may offer some relief for engorgement, but it is not the priority intervention at this time.
A nurse is teaching the parents of a newborn how to care for their child's uncircumcised penis. Which of the following instructions should the nurse include?
- A. Retract the foreskin until you feel resistance.
- B. Use a cotton swab to clean under the foreskin.
- C. Apply petroleum jelly to the foreskin.
- D. Wash the penis once per day with soup and water.
Correct Answer: D
Rationale: The correct answer is D because washing the penis once per day with soap and water is the appropriate way to care for an uncircumcised penis. This helps maintain good hygiene and prevents infections. Retracting the foreskin forcefully (Choice A) can cause injury and should not be done until the child is older. Using a cotton swab (Choice B) can leave fibers behind and may cause irritation. Applying petroleum jelly (Choice C) is unnecessary and can increase the risk of infections. Therefore, washing the penis with soap and water daily is the most effective and safe method for caring for an uncircumcised penis.
How can a nurse best prevent heat loss in a newborn during the first hour of life?
- A. Place the newborn under a radiant warmer
- B. Dry the newborn and cover with a warm blanket
- C. Place the newborn in a skin-to-skin position with the mother
- D. Keep the newborn wrapped in a wet blanket
Correct Answer: A
Rationale: The correct answer is A: Place the newborn under a radiant warmer. This method is the most effective in preventing heat loss in a newborn as radiant warmers provide a consistent heat source to maintain the newborn's body temperature. This is crucial during the first hour of life when newborns are at a higher risk of hypothermia.
Choice B is not as effective as using a radiant warmer as it may not provide enough warmth to prevent heat loss. Choice C, placing the newborn in a skin-to-skin position with the mother, is beneficial for bonding and regulating the newborn's temperature in the long term but may not be as effective as a radiant warmer in the immediate post-birth period.
Choice D, keeping the newborn wrapped in a wet blanket, is incorrect as wet blankets can further contribute to heat loss through evaporative cooling. In summary, using a radiant warmer is the best option for preventing heat loss in a newborn during the critical first hour of life.
A nurse is teaching a client who is at 41 weeks of gestation about a non-stress test. Which of the following information should the nurse include in the teaching?
- A. "This test will confirm fetal lung maturity ".
- B. "This test will determine adequacy of placental perfusion".
- C. "This test will detect fetal infection".
- D. "This test will predict maternal readiness for labor".
Correct Answer: B
Rationale: The correct answer is B: "This test will determine adequacy of placental perfusion." The non-stress test is used to assess fetal well-being by monitoring fetal heart rate in response to fetal movement. It helps determine if the placenta is providing enough oxygen and nutrients to the fetus. This information is crucial in assessing the overall health and viability of the fetus.
A: "This test will confirm fetal lung maturity" - This statement is incorrect because the non-stress test does not assess fetal lung maturity. That is usually done through tests like amniocentesis.
C: "This test will detect fetal infection" - This statement is incorrect because the non-stress test does not detect fetal infection. Other tests like amniocentesis or blood tests are used for this purpose.
D: "This test will predict maternal readiness for labor" - This statement is incorrect as the non-stress test focuses on fetal well-being and does not predict maternal readiness for labor.