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To prevent breast engorgement, what should the new breastfeeding mother be instructed to do?
- A. Feed her infant no more than every 4 hours.
- B. Limit her intake of fluids for the first few days.
- C. Apply cold packs to the breast prior to feeding.
- D. Breast-feed frequently and for adequate lengths of time.
Correct Answer: D
Rationale: The correct answer is D because frequent and adequate breastfeeding helps prevent breast engorgement by ensuring proper milk flow and emptying of the breasts. This stimulates milk production and prevents blockages. Choice A is incorrect as spacing out feedings can lead to engorgement. Choice B is incorrect as hydration is important for milk production. Choice C is incorrect as cold packs can reduce milk flow and hinder breastfeeding. In summary, frequent and effective breastfeeding is crucial in preventing breast engorgement.
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The nurse is performing the initial assessment of a newborn and notes retractions, nasal flaring, and tachypnea. The nurse will continue to perform a focused assessment on which system?
- A. Respiratory
- B. Cardiovascular
- C. Gastrointestinal
- D. Musculoskeletal
Correct Answer: A
Rationale: The correct answer is A: Respiratory. Retractions, nasal flaring, and tachypnea are signs of respiratory distress in a newborn. The nurse should focus on the respiratory system to assess the baby's breathing, lung sounds, oxygen saturation, and overall respiratory status. This is crucial for identifying any potential respiratory issues and providing prompt interventions.
Choices B, C, and D are incorrect because the symptoms described are specific to respiratory distress and do not indicate cardiovascular, gastrointestinal, or musculoskeletal issues. Focusing on these systems would not address the immediate concern of respiratory distress in the newborn.
A student nurse is caring for an infant who was just circumcised. What assessment finding should the student report to the registered nurse?
- A. No voiding for 8 hours
- B. Slight blood on the diaper
- C. Swelling on the glans penis
- D. Wishes to be held continuously
Correct Answer: A
Rationale: The nurse should assess for the first voiding after a circumcision to evaluate for urinary obstruction related to injury or swelling. Slight blood on the diaper would be expected. Some swelling may occur and does not cause concern unless it blocks the urethra. After a procedure, it is normal for an infant to wish to be held and comforted.
Which woman is most likely to continue breastfeeding beyond 6 months?
- A. A woman who avoids using bottles.
- B. A woman who uses formula for every other feeding.
- C. A woman who offers water or formula after breastfeeding.
- D. A woman whose infant is satisfied for 4 hours after the feeding.
Correct Answer: A
Rationale: The correct answer is A because avoiding bottles helps maintain the baby's preference for breastfeeding, leading to a higher likelihood of continuing beyond 6 months. Using formula for every other feeding (choice B) introduces a different feeding method, potentially reducing breastfeeding duration. Offering water or formula after breastfeeding (choice C) can reduce the baby's interest in breastfeeding exclusively. A satisfied baby for 4 hours after feeding (choice D) does not necessarily indicate a longer breastfeeding duration as other factors like feeding frequency play a role.
Upon discharge, parents of a newborn reveal their plans to take their newborn to the beach with them on a vacation when the newborn is 3 months old. Which statement by the nurse is the most appropriate?
- A. Newborns are encouraged to get at least 2 hours of sun each day for vitamin D synthesis.'
- B. You should make plans to leave your newborn with a relative or a babysitter while you are on vacation.'
- C. Sunscreen should be applied to your newborn every hour to prevent sunburn.'
- D. It is best to place your newborn in lightweight clothing and in the shade when outdoors.'
Correct Answer: D
Rationale: The correct answer is D because newborns have delicate skin that is highly susceptible to sunburn and heat-related issues. Placing the newborn in lightweight clothing and in the shade helps protect their sensitive skin from harmful UV rays. This approach minimizes the risk of sunburn and overheating.
A is incorrect because newborns should not be exposed to direct sunlight for prolonged periods. B is inappropriate as it is important for newborns to be with their parents for bonding and care. C is incorrect as sunscreen is not recommended for infants under 6 months of age due to potential skin irritation and absorption concerns.
The nurse recommends skin-to-skin contact immediately following the birth of a newborn because it reduces what type of heat loss?
- A. radiation
- B. convection
- C. conduction
- D. evaporation
Correct Answer: B
Rationale: Skin-to-skin contact minimizes heat loss through convection by reducing exposure to cooler air.