Nokea
The nurse advises the client to keep the newborn's crib free of which item?
- A. Soft toys and blankets
- B. Firm mattress
- C. Fitted sheet
- D. Crib bumpers
Correct Answer: A
Rationale: Soft toys and blankets in the crib increase the risk of suffocation and SIDS, and should be avoided.
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The laboring client suddenly experiences a dramatic drop in the FHR from the 150s to the 110s. A vaginal exam reveals the presence of the fetal cord protruding through the cervix. What should be the nurse’s first intervention?
- A. Put continuous pressure on the presenting part to keep it off the cord
- B. Place the bed in Trendelenburg position
- C. Insert a urinary catheter and instill saline
- D. Continue to monitor the FHR
Correct Answer: A
Rationale: The nurse should first exert continuous pressure on the presenting part to prevent further cord compression. This is continued until birth, which is usually by cesarean section. The bed should be placed in Trendelenburg position to further prevent pressure on the cord, but only after pressure is placed on the presenting part. A catheter may be inserted and 500 mL of warmed saline instilled to help float the head and prevent further compression, but only after pressure is placed on the presenting part. The fetus is continually monitored throughout until birth.
The postpartum client tells the nurse that she has pain when she breastfeeds. The nurse identifies that the infant has poor latch during breastfeeding. Which breast appearance shows that the client is experiencing symptoms associated with poor latch?
- A. Normal breasts
- B. Left breast with mastitis
- C. Engorged breasts
- D. Breasts with reddened, cracked nipples
Correct Answer: D
Rationale: This graphic shows normal breasts. This graphic shows the left breast with mastitis. Mastitis frequently presents as redness, warmth, and tenderness of the breast tissue, rather than the nipple. This graphic shows engorged breasts. This graphic shows breasts that have reddened nipples, one of which is cracked. If proper latch is not obtained during breastfeeding, the newborn’s sucking may cause nipple cracking, blistering, and bleeding.
An LPN asks an RN to assist in locating the fundus of the client who is 8 hours post—vaginal delivery. Place an X at the location on the client’s abdomen where the RN should direct the LPN to begin to palpate the fundus.
Correct Answer: Level of the umbilicus
Rationale: Six to 12 hours after birth, the fundus of the uterus rises to the level of the umbilicus due to blood and clots that remain within the uterus and changes in ligament support. Thus, the RN should direct the LPN to locate the client’s fundus at the level of the umbilicus.
Which expected outcome should the nurse include based on the client's eating habits?
- A. The client will eat three balanced meals and two snacks daily while pregnant.
- B. The client will gain a total of 50 pounds during the pregnancy.
- C. The client will take two prenatal vitamins daily.
- D. The client will report eating about 2,000 calories per day.
Correct Answer: A
Rationale: Eating three balanced meals and two snacks daily addresses the client's poor eating habits and supports nutritional needs.
When teaching the class about varicose veins, which symptom should the nurse instruct clients to report immediately?
- A. The appearance of additional varicose veins
- B. Varicose veins that are purple in color
- C. Legs that begin to ache and feel heavy
- D. Calves that become red, tender, and warm
Correct Answer: D
Rationale: Red, tender, warm calves may indicate deep vein thrombosis, a serious condition requiring immediate reporting.