Nokea
The nurse provides instructions to a new mother who is about to breastfeed her newborn infant. The nurse observes the new mother as she breastfeeds for the first time and determines the mother needs further teaching if the new mother applies which technique?
- A. Turns the newborn infant on his side, facing the mother
- B. Tilts up the nipple or squeezes the areola, pushing it into the newborn's mouth
- C. Draws the newborn the rest of the way onto the breast when the newborn opens his mouth
- D. Places a clean finger in the side of the newborn's mouth to break the suction before removing the newborn from the breast
Correct Answer: B
Rationale: The mother should avoid tilting up the nipple or squeezing the areola and pushing it into the newborn's mouth, as this can lead to improper latch or difficulties with milk flow. Turning the newborn on his side facing the mother, drawing the newborn onto the breast when the mouth opens, and breaking suction with a clean finger are appropriate breastfeeding techniques.
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The nurse is caring for a pregnant client at 24 weeks. The client voids before the nurse measures the fundal height. Which finding by the nurse would be expected in assessment of this client?
- A. a fundal height of 22 to 26 cm
- B. a fundal height of 27 to 30 cm
- C. a fundal height of 29 to 33 cm
- D. a fundal height of 31 to 34 cm
Correct Answer: A
Rationale: At 24 weeks, fundal height typically measures 22-26 cm, corresponding to gestational age in centimeters.
The nurse is participating in a free community health screening with a group of student nurses. Which statement by a student nurse requires further teaching by the licensed nurse?
- A. Colorectal cancer screening should begin at age 50.
- B. Men should have a prostate-specific antigen test starting at age 55.
- C. High-density lipoprotein should be greater than 50 mg/dL for women.
- D. Risk factors for hypertension include being over age 60 and leading a sedentary lifestyle.
Correct Answer: B
Rationale: Prostate-specific antigen testing typically starts at age 50, not 55, for average-risk men. Other statements are accurate.
The nurse is planning dietary counseling for the client with chronic heart failure taking triamterene. The nurse plans to include which item in a list of foods that are acceptable?
- A. Bananas
- B. Oranges
- C. Baked potato
- D. Canned pears
Correct Answer: D
Rationale: Triamterene is a potassium-retaining diuretic, so high-potassium foods like bananas, oranges, and potatoes should be avoided. Canned pears are lower in potassium, making them acceptable.
The nurse is planning to teach a teenage client about sexuality. What should the nurse do first?
- A. Inform the teenager about the dangers of pregnancy.
- B. Establish a relationship and determine prior knowledge.
- C. Advise the teenager to maintain sexual abstinence until marriage.
- D. Provide written information about sexually transmitted infections.
Correct Answer: B
Rationale: The first step in effective communication is establishing a relationship. By exploring the client's interest and prior knowledge, rapport is established, and learning needs are assessed. The other options may or may not be later steps, depending on the data obtained.
A postpartum client recovering from disseminated intravascular coagulopathy is to be discharged on low dosages of an anticoagulant medication. What action should the nurse encourage the client to avoid?
- A. Brushing her teeth
- B. Taking acetylsalicylic acid (aspirin)
- C. Walking long distances and climbing stairs
- D. All activities because bruising injuries can occur
Correct Answer: B
Rationale: Aspirin is an antiplatelet medication and can interact with the anticoagulant medication and increase the clotting time beyond therapeutic ranges, so avoiding aspirin is a priority. The client does not need to avoid brushing her teeth, but she should be instructed to use a soft toothbrush. Walking and climbing stairs are acceptable activities. Not all activities need to be avoided.