Nokea
The nurse educates the breastfeeding client diagnosed with mastitis. The nurse evaluates that the client has an adequate understanding of how to prevent mastitis in the future when the client makes which statements? Select all that apply.
- A. “Incorrect latch of my baby can lead to mastitis.”
- B. “I should perform hand hygiene before I breastfeed.”
- C. “I should rinse my baby’s mouth before I let her latch.”
- D. “A tight underwire bra has support that prevents mastitis.”
- E. “I should allow my nipples to air-dry after breastfeeding.”
Correct Answer: A,B,E
Rationale: Incorrect latch can cause nipple tissue to blister, crack, and bleed. These breaks in the tissue may serve as an entry point for pathogens. Hand hygiene prior to breastfeeding reduces the number of pathogens available for invasion. While the infant’s nose and throat are sources of pathogenic organisms that might cause mastitis, washing the infant’s mouth would be difficult and would not provide adequate protection for the mother. Wearing a tight bra, especially with an underwire, may restrict milk ducts, providing milk stasis and a medium for pathogenic growth. Allowing breasts to air-dry helps to reduce skin breakdown that might be caused by a moist, wet environment.
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On the basis of the health history data, how should the nurse record the client's pregnancy status on the prenatal records?
- A. Multipara
- B. Primipara
- C. Primigravida
- D. Multigravida
Correct Answer: C
Rationale: A primigravida is a woman pregnant for the first time, which matches the client's status of being possibly 2 months pregnant with no prior pregnancies.
The nurse is teaching the Muslim client how to correctly latch her baby to her breast for breastfeeding. Two student nurses are observing the instruction. Later, the client requests that the nurse not be allowed to provide her postpartum care. What most likely caused the client to be uncomfortable with the nurse?
- A. Muslim women do not want to breastfeed while in the hospital.
- B. Muslim women wait for their milk to come in before they breastfeed.
- C. Muslim women are uncomfortable breastfeeding in public situations.
- D. Muslim women only breastfeed after the infant is given boiled water.
Correct Answer: C
Rationale: Korean mothers resist breastfeeding in the hospital. Some Asian women believe colostrum is “bad,” and therefore they do not feed until actual breast milk is present. Most Muslim women breastfeed because the Koran encourages it; however, they are uncomfortable about breastfeeding in public situations and prefer privacy. Having two students observing the feeding process most likely would make the client uncomfortable, as she would desire more privacy. Some Asian cultures believe the newborn must be given boiled water until the milk is actually present.
The nurse includes which topic in the prenatal education plan for a first-time mother?
- A. Breastfeeding techniques
- B. Advanced labor pain management
- C. Neonatal surgical procedures
- D. Postpartum weight loss strategies
Correct Answer: A
Rationale: Breastfeeding techniques are essential for a first-time mother to ensure successful feeding and bonding with the newborn.
Multiple women are being seen in a clinic for various conditions. From which clients should the nurse prepare to obtain a group beta streptococcus (GBS) culture? Select all that apply.
- A. The client who is having symptoms of preterm labor
- B. The women who had a neonatal death 1 year ago
- C. All pregnant women coming to the clinic for care
- D. The women who had a spontaneous abortion 1 week ago
- E. The women who had an abortion for an unwanted pregnancy
Correct Answer: A,C
Rationale: The client in preterm labor should be screened for GBS infection. Between 10% and 30% of all women are colonized for GBS. All pregnant women, regardless of risk status, should be screened for GBS infection. Between 10% and 30% of all women are colonized for GBS. There is no indication that the client with a previous neonatal death is pregnant. The client would not be screened for GBS solely because of a history of spontaneous abortion. The client would not be screened for GBS solely because of an elective abortion.
The nurse uses which tool to measure fundal height?
- A. Tape measure
- B. Doppler device
- C. Ultrasound machine
- D. Blood pressure cuff
Correct Answer: A
Rationale: A tape measure is used to measure fundal height, assessing uterine growth and fetal development.