Nokea
The nurse observes a bottle-feeding multiparous client tilting the bottle so the nipple is partially filled with air. The nurse should:
- A. Instruct the client to tilt the bottle to fill the nipple with formula.
- B. Suggest switching to a different nipple size.
- C. Encourage burping the neonate more frequently.
- D. Document the observation as normal.
Correct Answer: A
Rationale: Tilting the bottle to fill the nipple prevents air swallowing, reducing the risk of gas and regurgitation.
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After instructing a primiparous client who is bottle-feeding about burping, which of the following client statements indicates that the client needs further teaching?
- A. I'll burp him after 15 minutes of feeding him formula.
- B. After he takes one-half ounce of formula, I'll burp him.
- C. I'll burp him while he is in an upright position.
- D. I'll gently pat his back to get him to burp.
Correct Answer: B
Rationale: Burping after one-half ounce is too frequent and may disrupt feeding; burping every 1-2 ounces is more appropriate.
A 38-year-old client at about 14 weeks' gestation is admitted to the hospital with a diagnosis of complete hydatidiform mole. Soon after admission, the nurse would assess the client for signs and symptoms of which of the following?
- A. Pregnancy-induced hypertension.
- B. Gestational diabetes.
- C. Hypothyroidism.
- D. Polycythemia.
Correct Answer: A
Rationale: Pregnancy-induced hypertension is a common complication of hydatidiform mole.
A nurse is discussing preterm labor in a prenatal class. After class, a client and her partner ask the nurse to identify again the nursing strategies to prevent preterm labor. The clients need further instruction when they state which of the following?
- A. "I need to stay hydrated all the time."
- B. "I need to avoid any infections."
- C. "I should include frequent rest breaks if we travel."
- D. "Changing to filter cigarettes is helpful."
Correct Answer: D
Rationale: Smoking, even with filter cigarettes, is harmful and should be avoided.
The physician orders an amniocentesis for a primigravid client at 35 weeks' gestation in early labor to determine fetal lung maturity. Which of the following is an indicator of fetal lung maturity?
- A. A amount of bilirubin present.
- B. Presence of red blood cells.
- C. Barr body determination.
- D. Lecithin-sphingomyelin (L/S ratio).
Correct Answer: D
Rationale: The lecithin-sphingomyelin (L/S) ratio in amniotic fluid is a key indicator of fetal lung maturity, with a ratio of 2:1 or higher indicating mature lungs. Bilirubin, red blood cells, and Barr body determination are not used for this purpose.
During the first hour after delivery, assessment of a multiparous client who delivered a neonate weighing 4,593 g (10 lb, 2 oz) by cesarean delivery reveals a soft fundus with excessive lochia rubra. The nurse should include which of the following in the client's plan of care?
- A. Administration of intravenous oxytocin.
- B. Placement of the client in a side-lying position.
- C. Rigorous fundal massage every 5 minutes.
- D. Preparation for an emergency hysteromyomectomy.
Correct Answer: A
Rationale: A soft fundus and excessive lochia suggest uterine atony, which is treated with oxytocin to promote uterine contraction.