Nokea
The nurse does not hear the baby swallow when suckling even though the baby appears to be latched properly to the breast. Which of the following situations may be the reason for this observation?
- A. The mother reports a pain level of 4 on a 5-point scale.
- B. The baby has been suckling for over 10 minutes.
- C. The mother uses the cross-cradle hold while feeding.
- D. The baby lies with the chin touching the under part of the breast.
Correct Answer: D
Rationale: Proper latch involves the chin touching the breast for efficient milk transfer.
You may also like to solve these questions
A nurse is doing a newborn assessment on a new admission to the nursery. Which of the following actions should the nurse make when evaluating the baby for developmental dysplasia of the hip (DDH)? Select one that doesn't apply
- A. Grasp the baby's legs with the thumbs on the inner thighs and forefingers on the outer thighs.
- B. Gently adduct and abduct the baby's thighs.
- C. Palpate the trochanter during hip rotation.
- D. Place the baby in a fetal position.
Correct Answer: D
Rationale: These maneuvers help detect instability or asymmetry in the hips indicative of DDH.
Which patient is more likely to have less stress adjusting to her role as a mother?
- A. A 26-year-old woman who is returning to work in 10 weeks
- B. A 35-year-old anxious mother who has had no contact with babies or children
- C. A 16-year-old teenager who lives with her parents and has a strained relationship with her mother
- D. A 25-year-old woman who knew at 16 weeks of gestation that she was pregnant with twins, who were delivered by cesarean birth
Correct Answer: A
Rationale: The correct answer is A because the 26-year-old woman who is returning to work in 10 weeks is more likely to have less stress adjusting to her role as a mother. This is because she is likely more established in her career, which can provide a sense of stability and financial security. Additionally, knowing she will return to work in 10 weeks can give her a sense of structure and purpose, reducing uncertainty and stress.
Choice B is incorrect because the 35-year-old anxious mother who has had no contact with babies or children may struggle with feelings of inadequacy and anxiety due to lack of experience with children.
Choice C is incorrect because the 16-year-old teenager living with strained relationship with her mother may face additional stressors from family dynamics and lack of maturity.
Choice D is incorrect because the 25-year-old woman who knew early in her pregnancy and delivered twins by cesarean birth may face physical challenges and increased demands of caring for twins, leading to higher stress levels.
Which action should the nurse take in order to provide support and encouragement to the new postpartum patient?
- A. Recount how she solved her own problems.
- B. Correct the new mother at every opportunity.
- C. Praise the mother’s early attempts at infant car
- D. Explain to the new mother that everything will be fine
Correct Answer: C
Rationale: The correct answer is C: Praise the mother’s early attempts at infant care. This choice focuses on positive reinforcement, which can boost the new mother's confidence and encourage her in her new role. By acknowledging and praising her efforts, the nurse can help build the mother's self-esteem and foster a supportive environment.
Choices A and D do not directly provide support and encouragement to the new mother. Recounting how the nurse solved her own problems (Choice A) may come off as self-centered and not helpful to the new mother's situation. Explaining that everything will be fine (Choice D) may minimize the new mother's feelings and concerns.
Choice B, correcting the new mother at every opportunity, is not supportive or encouraging. It can undermine the mother's confidence and create a negative dynamic. It is important for the nurse to focus on positive reinforcement and support to help the new mother navigate the challenges of postpartum care.
A gestational diabetic client, who delivered yesterday, is currently on the postpartum unit. Which of the following statements is appropriate for the nurse to make at this time?
- A. Monitor your blood glucose five times a day until your 6-week checkup.
- B. I will teach you how to inject insulin before you are discharged.
- C. Daily exercise will help to prevent you from becoming diabetic in the future.
- D. Your baby should be assessed every 6 months for signs of juvenile diabetes.
Correct Answer: A
Rationale: Gestational diabetes often resolves after delivery, but monitoring is still important.
The nurse assesses the fundus and finds it to be boggy, elevated >2 fingerbreadths above the umbilicus, and deviated to one side. What is the common cause of this finding?
- A. uterine rupture
- B. full bladder
- C. perineal laceration
- D. hematoma
Correct Answer: B
Rationale: The correct answer is B: full bladder. A full bladder can cause the fundus to be boggy, elevated, and deviated to one side due to impeding the uterus from contracting properly. This can lead to postpartum hemorrhage. Uterine rupture (A) would present with severe abdominal pain and signs of shock. Perineal laceration (C) would not cause these fundus changes. Hematoma (D) would present with localized swelling and pain, not fundal changes.