Nokea
The perinatal nurse assisting with establishing lactation is aware that acute mastitis can be minimized by
- A. Proper breastfeeding techniques
- B. Washing with mild soap and water once a day
- C. Wearing a supportive bra 24h
- D. Wearing a nipple shield first few days of breastfeeding
Correct Answer: A
Rationale: Acute mastitis is inflammation of the breast tissue that may result from milk stasis, inadequate milk removal, or bacteria entering the breast tissue through cracks in the nipple. One of the key ways to prevent acute mastitis is by ensuring proper breastfeeding techniques. This includes ensuring a good latch to allow for effective milk removal, practicing frequent and complete emptying of the breasts, and alternating the position of the baby during feeding to ensure all parts of the breast are drained. Proper breastfeeding techniques help to prevent milk stasis and reduce the risk of developing mastitis.
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The nurse is caring for a client at 38 weeks' gestation with suspected placental abruption. What is the priority nursing action?
- A. Assess maternal vital signs and fetal heart rate.
- B. Prepare the client for immediate cesarean delivery.
- C. Administer oxygen at 2 L/min via nasal cannula.
- D. Insert an indwelling urinary catheter.
Correct Answer: A
Rationale: Assessing maternal and fetal status is the first step to determine the urgency and appropriate intervention.
A patient has just been prescribed birth control pills and asks about possible side effects. Which of the following should be discussed with the patient?
- A. Increase in menstrual flow
- B. Headaches or nausea
- C. Decrease in libido
- D. Increased risk of breast cancer
Correct Answer: B
Rationale: Headaches and nausea are common side effects of oral contraceptives. Choice A is incorrect because birth control pills typically decrease the menstrual flow. Choice C is not commonly reported with oral contraceptives, and many women report no change in libido. Choice D is incorrect because while oral contraceptives may slightly increase the risk of certain cancers, breast cancer risk is not significantly elevated compared to the general population.
What is the primary nursing concern for a mother receiving magnesium sulfate therapy?
- A. Monitor blood pressure every 4 hours
- B. Monitor deep tendon reflexes hourly
- C. Assess respiratory rate and effort
- D. Prepare for delivery if signs of toxicity appear
Correct Answer: B
Rationale: Monitoring reflexes detects early signs of magnesium toxicity.
When the nurse is assisting a person desiring contraception, a history and physical is done. What is an important question the nurse should ask?
- A. What is your education level?
- B. Have you ever been pregnant?
- C. Are you married?
- D. What is your exercise routine?
Correct Answer: B
Rationale: When assisting a person desiring contraception, asking whether they have ever been pregnant is an important question because it helps the healthcare provider assess the individual's past reproductive history, including any pregnancies and potential complications. This information is important in determining the most suitable contraceptive options for the person, taking into account their previous experiences with pregnancy and childbirth. It can also help in evaluating the effectiveness of their past contraceptive methods and guide the selection of appropriate contraceptive counseling and options.
A nurse is caring for a client who is to undergo an amniotomy. Which of the following is the priority nursing action following this procedure?
- A. Observe color and consistency of fluid.
- B. Assess the fetal heart rate pattern.
- C. Assess the client's temperature.
- D. Evaluate client for the presence of chills and increased uterine tenderness using palpation.
Correct Answer: B
Rationale: The priority nursing action following an amniotomy (rupture of the amniotic sac) is to assess the fetal heart rate pattern. This is crucial to monitor for any signs of fetal distress or complications that may arise after the procedure. Changes in the fetal heart rate pattern can indicate the need for interventions to ensure the well-being of the fetus. Observing the color and consistency of the amniotic fluid, assessing the client's temperature, and evaluating for the presence of chills and increased uterine tenderness are also important assessments following amniotomy, but assessing the fetal heart rate takes precedence in this situation to ensure the safety of the fetus.