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A nurse is contributing to the plan of care for a client who is postpartum and has mastitis.
Which of the following actions should the nurse plan to take?
- A. Prepare the client for an abdominal sonogram.
- B. Encourage the client to continue to breastfeed
- C. Encourage the client to wear a bra that is loose fitting
- D. Limit the client's daily fluid intake.
Correct Answer: B
Rationale: Continuing to breastfeed is recommended for clients with mastitis. Breastfeeding helps to drain the breast and can speed up recovery. It also helps to prevent complications such as breast abscess and supports continued milk production.
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A nurse in a prenatal clinic is reinforcing teaching with a client who is at 20 weeks of gestation and has a low calcium level.
Which of the following foods should the nurse recommend the client increase in her diet?
- A. Peanut butter
- B. Avocados
- C. Yogurt
- D. Long-grain rice
Correct Answer: C
Rationale: Yogurt is an excellent calcium source, vital for fetal bone development and maternal health, making it the best recommendation for low calcium levels.
A nurse is collecting data from a client who is at 26 weeks of gestation and whose last appointment was 1 month ago.
Which of the following findings should the nurse report to the provider?
- A. Pedal edema
- B. BP of 132/84 mm Hg
- C. Weight gain of 1 kg (2.2 lb)
- D. Double vision
Correct Answer: D
Rationale: Double vision can indicate preeclampsia or other serious conditions in pregnancy, requiring prompt reporting for further evaluation and management.
A nurse is caring for a client who is at 9 weeks of gestation and reports nausea in the morning that continues until midafternoon.
Which of the following actions should the nurse encourage the client to take?
- A. Restrict fluids to 1,000 mL/day.
- B. Take an over-the-counter antacid
- C. Increase intake of fresh fruits
- D. Eat dry, bland foods in the morning
Correct Answer: D
Rationale: Encouraging the client to eat dry, bland foods in the morning, like crackers or toast, can help alleviate nausea associated with morning sickness by settling the stomach, making it an effective strategy.
A nurse is contributing to the plan of care for a newborn who requires phototherapy for hyperbilirubinemia.
Which of the following interventions should the nurse recommend including in the plan?
- A. Reposition the newborn every 2 to 3 hr.
- B. Monitor the newborn's blood glucose level every 2 hr.
- C. Give the newborn 30 ml of distilled water after each feeding.
- D. Apply a water-based ointment to the newborn's skin every 4 to 6 hr.
Correct Answer: A
Rationale: Repositioning the newborn every 2 to 3 hours helps ensure uniform exposure to the phototherapy lights, maximizing the effectiveness of the treatment. This prevents uneven distribution of light and reduces the risk of pressure ulcers or skin breakdown from prolonged immobility.
A nurse is caring for a client who had a vaginal delivery 4 hr ago and reports perineal pain of 6 on a scale of 0 to 10.
Which of the following actions should the nurse take?
- A. Offer an ice pack to the client during the first 24 hr.
- B. Apply a corticosteroid cream to the perineal area twice daily.
- C. Increase the client's fluid intake for 48 hr.
- D. Catheterize the client's bladder.
Correct Answer: A
Rationale: Offering an ice pack reduces inflammation and numbs the perineal area, providing effective pain relief in the immediate postpartum period after vaginal delivery.