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The nurse is teaching a multiparous breast-feeding client about managing mastitis. Which instruction is most appropriate?
- A. Stop breast-feeding until symptoms resolve.
- B. Apply warm compresses before feeding.
- C. Take antibiotics only if fever persists.
- D. Massage the breast vigorously during feeding.
Correct Answer: B
Rationale: Warm compresses before feeding promote milk flow and relieve duct blockage, aiding mastitis resolution.
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Which of the following instructions about activities during menstruation would the nurse include when counseling an adolescent who has just begun to menstruate?
- A. Take a mild analgesic if needed for menstrual pain.
- B. Avoid cold foods if menstrual pain persists.
- C. Stop exercise while menstruating.
- D. Avoid sexual intercourse while menstruating.
Correct Answer: A
Rationale: Mild analgesics like ibuprofen can effectively manage menstrual pain. There is no evidence supporting avoiding cold foods, and moderate exercise can alleviate cramps. Sexual intercourse during menstruation is a personal choice and not medically contraindicated.
A neonate born by cesarean delivery at 42 weeks' gestation, weighing 4.1 kg (9 lb, 1 oz), with Apgar scores of 8 at 1 minute and 9 at 5 minutes after birth, develops an increased respiratory rate and tremors of the hands and feet 2 hours postpartum. Which of the following nursing diagnoses would be the priority?
- A. Ineffective airway clearance related to postterm gestational age.
- B. Hyperthermia related to large size and use of a radiant warmer.
- C. Decreased cardiac output related to difficult delivery.
- D. Imbalanced nutrition: Less than body requirements related to depleted glycogen stores.
Correct Answer: D
Rationale: Tremors and increased respiratory rate suggest hypoglycemia due to depleted glycogen stores, a common issue in post-term neonates.
Which of the following statements about a fetal biophysical profile would be incorporated into the teaching plan for a primigravid client with insulin-dependent diabetes?
- A. It determines fetal lung maturity.
- B. It is noninvasive using real-time ultrasound.
- C. It will correlate with the newborn's Apgar score.
- D. It requires the client to have an empty bladder.
Correct Answer: B
Rationale: Biophysical profiles are noninvasive and use real-time ultrasound.
The nurse on a mother-baby unit who is working on the night shift is revising the planning worksheet for the remaining 2 hours of the shift. The nurse has the following tasks and orders to complete prior to the 7 a.m. change of shift. Using the work plan below, how should the nurse organize the following tasks so that everything is completed by 7 a.m.?
- A. Draw blood for the ordered laboratory tests (CBCs) on 3 postpartum clients with report on charts by shift change.
- B. Start IV of D5 1/2 NS at keep vein open (KVO) rate on postpartum client just prior to change of shift.
- C. Complete admission assessment of newborn turned over to nurse at 5 a.m.
- D. Draw newborn bilirubin level at 6 a.m.
Correct Answer: A,C,D,B
Rationale: 5:00 - Complete admission assessment; 5:30 - Draw CBCs; 6:00 - Draw bilirubin; 6:30 - Start IV. This ensures timely completion.
When developing the plan of care for a multiparous client in active labor who receives an epidural anesthetic, which of the following would the nurse anticipate that the physician will order if the client develops moderate hypotension?
- A. Ephedrine sulfate.
- B. Epinephrine (Adrenalin Chloride).
- C. Methylergonovine (Methergine).
- D. Atropine sulfate.
Correct Answer: A
Rationale: Ephedrine sulfate is commonly used to treat epidural-related hypotension by increasing blood pressure through vasoconstriction and cardiac stimulation. Epinephrine is for emergencies, methylergonovine treats uterine atony, and atropine addresses bradycardia.