Nokea
The nurse notes the following vital signs of a postoperative cesarean client during the immediate postpartum period: 100.0°F, P 68, R 12, BP 130/80. Which of the following is a correct interpretation of the findings?
- A. Temperature is elevated, a sign of infection.
- B. Pulse is too low, a sign of vagal pathology.
- C. Respirations are too low, a sign of medication toxicity.
- D. Blood pressure is elevated, a sign of preeclampsia.
Correct Answer: C
Rationale: Low respirations may indicate opioid toxicity.
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The nurse educates the non–breast-feeding person on breast discomfort caused by engorgement. What instructions would they give?
- A. Massage breasts to release milk.
- B. Apply cold packs and cabbage leaves.
- C. Stand in the warm shower to stimulate letdown.
- D. Do not wear a bra.
Correct Answer: B
Rationale: The correct answer is B: Apply cold packs and cabbage leaves. Engorgement causes breast swelling and discomfort due to increased blood and milk supply. Applying cold packs reduces inflammation and pain. Cabbage leaves have a cooling effect and can help reduce swelling. Massaging breasts can worsen engorgement by stimulating more milk production. Standing in a warm shower may provide temporary relief but does not address the root cause. Not wearing a bra may lead to discomfort and does not alleviate engorgement.
The nurse is concerned that a bottle-fed baby may become obese because of which activity by the mother?
- A. She encourages the baby to finish the bottle at each feed.
- B. She feeds the baby every 3 to 4 hours.
- C. She feeds the baby a soy-based formula.
- D. She burps the baby every 1/2 to 1 ounce.
Correct Answer: A
Rationale: Overfeeding can contribute to obesity.
A baby boy is to be circumcised by the mother's obstetrician. Which of the following actions shows that the nurse is being a patient advocate?
- A. Before the procedure
- B. the nurse prepares the sterile field for the physician.
- C. The nurse refuses to unclothe the baby until the doctor orders something for pain.
- D. The nurse holds the feeding immediately before the circumcision.
Correct Answer: B
Rationale: Ensuring pain management demonstrates advocacy for the baby's comfort and safety.
A female African American baby has been admitted into the nursery. Which of the following physiological findings would the nurse assess as normal?Select one that doesn't apply
- A. Purple-colored patches on the buttocks and torso.
- B. Bilateral whitish discharge from the breasts.
- C. Bloody discharge from the vagina.
- D. Sharply demarcated dark red area on the face.
Correct Answer: D
Rationale: Transient phenomena such as mongolian spots, witch's milk, and pseudo-menstruation are normal in newborns.
A client is receiving a blood transfusion after the delivery of a placenta accreta and hysterectomy. Which of the following complaints by the client would warrant immediately discontinuing the infusion?
- A. My lower back hurts all of a sudden.
- B. My hands feel so cold.
- C. I feel like my heart is beating fast.
- D. I feel like I need to have a bowel movement.
Correct Answer: A
Rationale: Back pain can indicate a hemolytic reaction.