Nokea
The nurse is caring for a Seventh Day Adventist woman who delivered a baby boy by cesarean section. Which of the following questions should be asked regarding this woman 's care?
- A. Would you like me to order a vegetarian clear liquid diet for you?
- B. Is there anything special you will need for your Sabbath on Sunday?
- C. Would you like to telephone your clergy to set up a date for the baptism?
- D. Will a rabbi be performing the circumcision on your baby?
Correct Answer: B
Rationale: Seventh Day Adventists observe the Sabbath on Saturday. The nurse should ask if special arrangements are needed for Sabbath observance.
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A woman has an 8-lb, 9-oz baby after an 18-hour labor that required a vacuum extraction. Her membranes have been ruptured for 15 hours. Based on these facts, client teaching should emphasize:
- A. Reporting foul-smelling lochia and fever.
- B. Delaying intercourse for at least 6 weeks.
- C. Eating a diet that is high in iron and vitamin C.
- D. Losing weight over at least a 6-month period.
Correct Answer: A
Rationale: Prolonged rupture of membranes increases the risk of infectionand the woman should report any signs of infection such as foul-smelling lochia or fever.
The nurse educates the person with a newborn in the NICU. What guidance does the nurse provide?
- A. Breast milk is not good for a premature baby.
- B. Premature babies breast-feed easily.
- C. Skin-to-skin contact helps both baby and breast-feeding person.
- D. A bottle is recommended for all feedings.
Correct Answer: C
Rationale: The correct answer is C because skin-to-skin contact promotes bonding, regulates the baby's temperature, and encourages breastfeeding. This guidance is crucial for newborns in the NICU to establish a strong connection with their caregiver and support breastfeeding. Choice A is incorrect as breast milk is highly beneficial for premature babies. Choice B is incorrect because premature babies may struggle with breastfeeding due to their developmental stage. Choice D is incorrect as bottles are not recommended for all feedings, especially for premature infants who may have difficulty latching and feeding effectively.
What assessment finding suggests a possible infection?
- A. painful fundal massage
- B. breast-feeding every 2–3 hours
- C. pulse 72
- D. WBCs 10,000
Correct Answer: D
Rationale: The correct answer is D: WBCs 10,000. An elevated white blood cell count (WBC) is a common sign of infection as the body produces more WBCs to fight off pathogens. This increase in WBC count is known as leukocytosis and is a key indicator of an ongoing infection. In contrast, choices A, B, and C are not direct indicators of infection. A painful fundal massage may suggest uterine atony, breast-feeding every 2-3 hours is a normal part of postpartum care, and a pulse rate of 72 is within the normal range. Therefore, the most reliable assessment finding suggesting a possible infection is an elevated WBC count.
What assessment data increases the risk of postpartum infection?
- A. precipitous labor
- B. urinary retention
- C. breast-feeding
- D. intact perineum
Correct Answer: A
Rationale: Precipitous labor can increase the risk of infection due to the rapid and potentially traumatic delivery process.
A breastfeeding mother states that she has sore nipples. In response to the complaint, the nurse assists with 'latch on ' and recommends that the mother do which of the following?
- A. Use a nipple shield at each breastfeeding.
- B. Cleanse the nipples with soap 3 times a day.
- C. Rotate the baby 's positions at each feed.
- D. Bottle feed for 2 days then resume breastfeeding.
Correct Answer: C
Rationale: Rotating positions during breastfeeding helps to prevent sore spots and promotes proper latch.