Nokea
The nurse is completing discharge instructions with a new mother and is concerned about her safety. Which statement by the client indicates the client needs further instructions?
- A. I will need to be checked out by the doctor in a week.
- B. I need to wear a sports bra for a few days so I don't get milk.
- C. I can get pregnant now if I don't use birth control.
- D. I may feel sad for a few days but should be OK within a few days.
Correct Answer: B
Rationale: Wearing a sports bra does not prevent milk production; this statement indicates a misunderstanding of lactation suppression.
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At which of the following locations would the nurse expect to palpate the fundus of a primiparous client immediately after delivery of a neonate?
- A. Halfway between the umbilicus and the symphysis.
- B. At the level of the umbilicus.
- C. Just below the level of the umbilicus.
- D. Above the level of the umbilicus.
Correct Answer: B
Rationale: Immediately after delivery, the fundus is typically at the level of the umbilicus due to the uterus beginning to involute.
A client asks about the benefits of the hormonal IUD. Which of the following responses by the nurse is accurate?
- A. It can reduce menstrual bleeding over time.
- B. It provides protection against HIV.
- C. It requires replacement every 6 months.
- D. It is not suitable for women with irregular periods.
Correct Answer: A
Rationale: The hormonal IUD can reduce menstrual bleeding over time, often leading to lighter periods or amenorrhea. It does not protect against HIV, lasts 3-7 years, and is suitable for irregular periods.
Twenty-four hours after cesarean delivery, a neonate at 30 weeks' gestation is diagnosed with respiratory distress syndrome (RDS). When explaining to the parents about the cause of this syndrome, the nurse should include a discussion about an alteration in the body's secretion of which of the following?
- A. Somatotropin.
- B. Surfactant.
- C. Testosterone.
- D. Progesterone.
Correct Answer: B
Rationale: RDS is caused by insufficient surfactant production, which is critical for lung expansion and preventing alveolar collapse.
The father of a neonate diagnosed with gastroschisis tells the nurse that his wife had planned on breast-feeding the neonate. Which of the following should the nurse include in the preoperative teaching plan about feeding the neonate?
- A. The neonate will remain on nothing-by-mouth (NPO) status until after surgery.
- B. An iron-fortified formula will be given before surgery.
- C. The neonate will need total parenteral nutrition for nourishment.
- D. The mother may breast-feed the neonate before surgery.
Correct Answer: A
Rationale: The neonate must remain NPO before surgery to prevent complications related to the exposed intestines.
While the nurse is caring for a primiparous client on the first postpartum day, the client asks, "How is that woman doing who lost her baby from prematurity?" Which of the following responses by the nurse would be most appropriate?
- A. Ignore the client's question and continue with morning care.
- B. Tell the client "I'm not sure how the other woman is doing today."
- C. Tell the client "I need to ask the woman's permission before discussing her well-being."
- D. Explain to the client that "Nurses are not allowed to discuss other clients on the unit."
Correct Answer: D
Rationale: Nurses must maintain patient confidentiality, making it inappropriate to discuss another client's status.