Nokea
The nurse is evaluating a breastfeeding session. The nurse determines that the infant has appropriately latched on to the mother’s breast when which observations are made? Select all that apply.
- A. The mother reports a firm tugging feeling on her nipple.
- B. A smacking sound is heard each time the baby sucks.
- C. The infant’s mouth covers only the mother’s nipple.
- D. The baby’s nose, mouth, and chin are touching the breast.
- E. The infant’s cheeks are rounded when sucking.
- F. The infant’s swallowing can be heard after sucking.
Correct Answer: A,D,E,F
Rationale: If the latch is correct, the mother should feel only a firm tugging and not pain or pinching when the infant sucks. A smacking or clicking noise heard when the infant sucks is an indication that the latch is incorrect and that the infant’s tongue may be inappropriately placed. Sucking only on the mother’s nipple will cause sore nipples, and milk will not be ejected from the milk ducts. When an infant is correctly latched to the breast, 2 to 3 centimeters (1/3 to 3/4 inch) of areola should be covered by the infant’s mouth. If this occurs, it will result in the infant’s nose, mouth, and chin touching the breast. When the infant is latched correctly, the cheeks will be rounded rather than dimpled. When the infant is latched correctly, the swallowing will be audible.
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The nurse is providing nutrition counseling to the client during her first prenatal clinical visit. Which statement, if made by the client, indicates that the client has an understanding of some of the nutritional requirements during pregnancy?
- A. “I can eat cheese as an alternative to milk, as I don’t care for milk.”
- B. “I should be eating more at each meal because I’m eating for two.”
- C. “I will need to limit my calories because I am already overweight.”
- D. “I should limit myself to eating only three healthy meals per day.”
Correct Answer: A
Rationale: Cheese is a milk product and is an alternative to milk. This statement indicates understanding of nutritional requirements regarding milk and milk products. Caloric intake needs to increase by 300 kcal per day during pregnancy to meet increased metabolic needs. However, “I’m eating for two” is a common misconception and leads to caloric intake greater than necessary. Caloric intake needs to increase by 300 kcal per day and should not be limited during pregnancy. Nutritional snacks throughout the day can provide for steady blood glucose levels and decrease the nausea associated with pregnancy. A limit of only three meals per day may not provide the client with enough calories to meet increased metabolic needs or may cause the client to eat more at each meal and increase nausea and bloating.
The nurse observes a sinusoidal FHR pattern on the monitor tracing. How should the nurse interpret this pattern?
- A. The fetus may be in a sleep state.
- B. Congenital anomalies are possible.
- C. This may indicate severe fetal anemia.
- D. This predicts normal fetal well-being.
Correct Answer: C
Rationale: A sinusoidal pattern, which is Drag and Drop, smooth, undulating, and uncommon, classically occurs with severe fetal anemia as a result of abnormal perinatal conditions. An FHR pattern having minimal variability (not a sinusoidal pattern) might indicate that the fetus is in a sleep state. Absent or minimal variability, not a sinusoidal FHR pattern, could indicate possible congenital anomalies. Moderate variability of the FHR (not a sinusoidal pattern) reflects normal fetal well-being.
The nurse is evaluating the 39-weeks-pregnant client who reports greenish, foul-smelling vaginal discharge. Her temperature is 101.6°F (38.7°C), and the FHR is 120 with minimal variability and no accelerations. The client’s group beta streptococcus (GBS) culture is positive. Which interventions should the nurse plan to implement? Select all that apply.
- A. Prepare for cesarean birth due to chorioamnionitis
- B. Start oxytocin for labor induction
- C. Start antibiotics as directed for the GBS infection
- D. Prepare the client for epidural anesthesia
- E. Notify the neonatologist of the client’s status
- F. Administer a cervical ripening agent
Correct Answer: A,C,D,E
Rationale: Because this client is not in labor and chorioamnionitis is possible, a cesarean birth is indicated. The client should be given antibiotics as prescribed to treat the infection. Because epidural anesthesia offers the least risk to the fetus, preparation for epidural anesthesia should begin. The pediatrician or neonatologist should be notified and available for the impending delivery. Starting oxytocin (Pitocin) would prolong the time to delivery. Administering a cervical ripening agent would prolong the time to delivery.
Which response by the nurse is most relevant when another participant talks about having recurrent mood swings?
- A. Try to avoid fatigue and decrease your stress.
- B. You need to be assessed for a possible mood disorder.
- C. Mood swings are caused by increased blood volume.
- D. Are you ambivalent about the pregnancy?
Correct Answer: A
Rationale: Avoiding fatigue and stress helps manage mood swings, which are common due to hormonal changes in pregnancy.
Which of the following is most indicative of the presence of hydatidiform mole?
- A. A blotchy brown discoloration on the face
- B. A positive Chadwick's sign
- C. The presence of ballottement
- D. A uterus that is larger than expected
Correct Answer: D
Rationale: A uterus larger than expected for gestational age is characteristic of hydatidiform mole, a gestational trophoblastic disease.