Nokea
When caring for a multiparous client who is human immunodeficiency virus (HIV)-positive and asking to breast-feed her neonate as soon as possible, which of the following instructions about breast milk should the nurse include in the teaching plan?
- A. It does not help prevent the spread of the HIV virus.
- B. It contains antibodies that can protect the neonate from HIV.
- C. It can be beneficial for the bonding process.
- D. It has been found to contain the contain the retrovirus HIV.
Correct Answer: D
Rationale: Breast milk from an HIV-positive mother can transmit the virus to the neonate, so breastfeeding is contraindicated to prevent HIV transmission.
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A primiparous client with a neonate who is 36 hours old asks the nurse, "Why does my baby spit up a small amount of formula after feeding?" The nurse explains that the regurgitation is thought to result from which of the following?
- A. An immature cardiac sphincter.
- B. A defect in the gastrointestinal system.
- C. Burping the infant too frequently.
- D. Moving the infant during the feeding.
Correct Answer: A
Rationale: An immature cardiac sphincter in newborns can cause regurgitation of formula.
A primiparous client post-cesarean asks about preventing constipation. The nurse should recommend:
- A. Limiting fluid intake to avoid bladder distention.
- B. Eating a low-fiber diet for the first week.
- C. Increasing intake of fruits and whole grains.
- D. Taking a laxative daily for 2 weeks.
Correct Answer: C
Rationale: Fruits and whole grains provide fiber, promoting regular bowel movements and preventing constipation.
Which of the following measures would the nurse expect to include in the teaching plan for a multiparous client who delivered 24 hours ago and is receiving intravenous antibiotic therapy for cystitis?
- A. Limiting fluid intake to 1 L daily to prevent overload.
- B. Catheterizing the bladder every 2 to 4 hours while awake.
- C. Washing the perineum with povidone iodine (Betadine) after voiding.
- D. Avoiding the intake of acidic fruit juices until the treatment is discontinued.
Correct Answer: D
Rationale: Avoiding acidic juices reduces bladder irritation during cystitis treatment.
The physician orders betamethasone (Celestone) for a 34-year-old multigravid client at 32 weeks' gestation who is experiencing preterm labor. Previously, the client has experienced one infant death due to preterm birth at 28 weeks' gestation. The nurse explains that this drug is given for which of the following reasons?
- A. To enhance fetal lung maturity.
- B. To counter the effects of tocolytic therapy.
- C. To treat chorioamnionitis.
- D. To decrease neonatal production of surfactant.
Correct Answer: A
Rationale: Betamethasone enhances fetal lung maturity.
During the first hour after a precipitous delivery, the nurse should monitor a multiparous client for signs and symptoms of which of the following?
- A. Postpartum 'blues.'
- B. Uterine atony.
- C. Intrauterine infection.
- D. Urinary tract infection.
Correct Answer: B
Rationale: Precipitous delivery increases the risk of uterine atony due to rapid labor, potentially causing postpartum hemorrhage. Postpartum blues, intrauterine infection, or urinary tract infection are less immediate concerns.