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Which nursing intervention is most appropriate for a breastfeeding mother experiencing engorgement?
- A. Apply cold compresses to the breasts after feeding
- B. Limit breastfeeding to every 6 hours
- C. Use formula supplements to reduce milk supply
- D. Massage the breasts before feeding
Correct Answer: A
Rationale: Cold compresses reduce swelling and discomfort during engorgement.
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The nurse teaches a new mother that neonatal weight loss in the first 3 days of life is most often the result of:
- A. Allergy to formula
- B. a hypoglycemic response
- C. Inadequate breast or formula feeding
- D. Excretion of fluid via lungs, urinary bladder and bowels.
Correct Answer: C
Rationale: Neonatal weight loss in the first 3 days of life is most often the result of inadequate breast or formula feeding. During the initial days of life, it is normal for newborn babies to experience some weight loss. This weight loss is generally due to factors such as insufficient intake of breast milk or formula. It takes a few days for a mother's mature breast milk to come in, and during this time, a newborn may not receive enough colostrum, which can lead to initial weight loss. Similarly, if a baby is not getting enough formula or is having feeding difficulties, this can also result in weight loss. Allergy to formula, a hypoglycemic response, or excretion of fluid via lungs, urinary bladder, and bowels are less likely explanations for neonatal weight loss in the first 3 days of life compared to inadequate feeding.
A nurse is planning care for a newborn who is scheduled to start phototherapy using a lamp. Which of the following actions should the nurse include in the plan?
- A. Apply a thin layer of lotion to the newborn skin every 8 hrs.
- B. Give the newborn 1oz of glucose water every 4 hrs.
- C. Ensure the newborn eyes are closed beneath the shield.
- D. Dress the newborn in a thin layer of clothing during therapy
Correct Answer: C
Rationale: The correct action the nurse should include in the care plan for a newborn undergoing phototherapy using a lamp is to ensure that the newborn's eyes are closed beneath the shield. This is important to protect the newborn's eyes from exposure to the bright light emitted during phototherapy, as prolonged exposure can lead to eye damage. Keeping the eyes closed under the shield helps prevent potential harm and ensures the safety and well-being of the newborn during the treatment. Applying a thin layer of lotion, giving glucose water, or dressing the newborn in clothing are not relevant or appropriate actions for phototherapy care in this scenario.
The nurse is educating a client about signs of labor. Which statement indicates understanding?
- A. False labor contractions cause cervical changes.
- B. True labor contractions decrease with activity.
- C. True labor contractions become stronger and more regular.
- D. False labor contractions are felt in the back.
Correct Answer: C
Rationale: True labor is characterized by regular, strong contractions that lead to cervical changes.
A woman admitted to the labor and delivery unit in bruising over the shoulder area and an abrasion on early labor gives the following obstetric history. She the scalp. What are these markings most likely the gave birth to her daughter at 38 weeks and her twin result of?
- A. Suspected drug use during pregnancy
- B. Abuse by a caregiver
- C. Soft tissue injury during delivery
- D. Blue/gray macule (Mongolian spot)
Correct Answer: B
Rationale: The bruising over the shoulder area and the abrasion on the scalp of a woman admitted to the labor and delivery unit during early labor are most likely the result of abuse by a caregiver. These types of injuries can be indicative of physical abuse, especially in vulnerable populations such as pregnant women. It is important for healthcare providers to be alert for signs of abuse and to report any suspicions or evidence to ensure the safety of the mother and the baby. In cases like this, a thorough assessment and appropriate intervention are necessary to protect the well-being of the mother and the unborn child.
The nurse is caring for a client at 39 weeks' gestation in active labor. The fetal monitor shows late decelerations. What is the priority nursing action?
- A. Reposition the client to her left side.
- B. Increase the oxytocin infusion rate.
- C. Encourage the client to push harder.
- D. Notify the healthcare provider immediately.
Correct Answer: A
Rationale: Repositioning improves uteroplacental blood flow and oxygen delivery to the fetus, addressing late decelerations.