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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Which screening is recommended for a client over 35 years old?
- A. Amniocentesis for genetic disorders
- B. Blood type screening
- C. Urine culture
- D. Basic ultrasound
Correct Answer: A
Rationale: Amniocentesis is recommended for women over 35 to screen for genetic disorders due to increased risk with advanced maternal age.
The nurse is teaching the pregnant client during her first trimester. The nurse identifies that which decision is most important for her to make first?
- A. Bottle versus breastfeeding
- B. Labor and delivery location
- C. Pain management during labor
- D. Method for delivery of the baby
Correct Answer: B
Rationale: A decision regarding labor and delivery location is the priority for the client in order to properly plan for a home birth versus a hospital birth, HCP availability at the location, and type of labor and delivery settings available at the location. The decision on feeding the newborn can be made up to the time of the first feeding. The decision on pain management can be made early but can be changed up through the early stages of labor. The decision of delivery method should be made early but cannot be determined until the decision is made on labor and delivery location.
Which position should the nurse recommend for early labor?
- A. Lying flat on the back
- B. Walking or standing
- C. Sitting upright
- D. Kneeling on all fours
Correct Answer: B
Rationale: Walking or standing in early labor promotes progress and comfort, unlike lying flat, which may slow labor.
The nurse is caring for the pregnant client at the initial prenatal visit. Which universal screenings should the nurse complete? Select all that apply.
- A. Taking the client’s blood pressure
- B. Doing a urine dipstick test for protein
- C. Doing a urine dipstick test for glucose
- D. Asking questions about domestic violence
- E. Asking questions about use of tobacco
Correct Answer: A,D,E
Rationale: BP screening should be performed at the initial prenatal visit to establish a baseline and to evaluate for actual or potential problems. Domestic violence screening should be performed at the initial prenatal visit to determine fetal and maternal risk for harm. Screening for tobacco use should be performed at the initial prenatal visit to determine fetal and maternal risk. Smoking is associated with an increased risk for spontaneous abortion, preterm labor, and low birth weight. The use of routine urine dip assessments is unreliable in detecting proteinuria and is not always considered accurate. A urine sample should be collected and a UA completed to check for a UTI. The urine dipstick test is of insufficient sensitivity to be used as a screening tool for glycosuria and is not always considered accurate. A urine sample should be collected and a UA completed to check for the presence of glucose.
The nurse is counseling the client who is trying to become pregnant. To promote fetal health when the client is unaware of a pregnancy, the nurse should stress the inclusion of which nutrient in daily food intake?
- A. Potassium
- B. Calcium
- C. Folic acid
- D. Sodium
Correct Answer: C
Rationale: The nurse should educate the client about the need for adequate folic acid intake. Folic acid is important in preventing neural tube defects, especially during the first four weeks of fetal development. Potassium is important in preventing leg cramps during pregnancy, but this is usually not an issue during the first four weeks of gestation. Calcium is important for fetal development of bones, teeth, heart, nerves, and muscles, but the fetus will take calcium from the mother. Calcium is more important to maternal health than fetal development. Sodium is important for maintaining optimal electrolyte balance but is typically ingested in more than adequate amounts in a typical diet.