Nokea
Which of the following actions would encourage the baby to open the mouth wide for feeding?
- A. Holding the baby in the en face position.
- B. Pushing down on the baby's lower jaw.
- C. Tickling the baby's lips with the nipple.
- D. Giving the baby a trial bottle of formula.
Correct Answer: C
Rationale: Tickling the lips stimulates rooting reflex.
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A client is being discharged on Coumadin (warfarin) post-pulmonary embolism after a cesarean delivery. Which of the following should be included in the patient teaching?
- A. Take only ibuprofen for pain.
- B. Avoid overeating dark green, leafy vegetables.
- C. Drink grapefruit juice daily.
- D. Report any decrease in urinary output.
Correct Answer: B
Rationale: Leafy greens affect INR levels.
Which clinical finding should the nurse suspect if the fundus is palpated on the right side of the abdomen above the expected level?
- A. Distended bladder
- B. Normal involution
- C. Been lying on her right side too long
- D. Stretched ligaments that are unable to support the uterus
Correct Answer: A
Rationale: The correct answer is A, a distended bladder. When the fundus is palpated on the right side above the expected level, it indicates that the bladder is full and pushing the uterus upward and to the right. This can interfere with the normal descent of the uterus during involution, leading to the fundus being higher than expected.
Choice B, normal involution, is incorrect as it does not explain the fundus being palpated above the expected level.
Choice C, lying on her right side too long, is incorrect as body position does not typically result in the fundus being displaced.
Choice D, stretched ligaments that are unable to support the uterus, is incorrect as stretched ligaments would not cause the fundus to be palpated above the expected level; rather, it would lead to a lower position of the uterus.
A client has been receiving magnesium sulfate for severe preeclampsia for 12 hours. Her reflexes are 0 and her respiratory rate is 10. Which of the following situations could be a precipitating factor in these findings?
- A. Apical heart rate 104 bpm.
- B. Urinary output 240 mL/12 hr.
- C. Blood pressure 160/120.
- D. Temperature 100°F.
Correct Answer: B
Rationale: Decreased urinary output can lead to magnesium toxicity.
A nurse is assessing a 1-day postpartum client who had a spontaneous vaginal delivery over an intact perineum. The fundus is firm at the umbilicus, lochia moderate, and perineum edematous. One hour after receiving ibuprofen 600 mg po, the client is complaining of perineal pain at level 9 on a 10-point scale. Based on this information, which of the following is an appropriate conclusion for the nurse to make about the client?
- A. She should be assessed by her doctor.
- B. She should have a sitz bath.
- C. She may have a hidden laceration.
- D. She needs a narcotic analgesic.
Correct Answer: C
Rationale: Hidden lacerations can cause severe pain.
A woman states that all of a sudden her 4-day-old baby is having trouble feeding. On assessment, the nurse notes that the mother's breasts are firm, red, and warm to the touch. The nurse teaches the mother manually to express a small amount of breast milk from each breast. Which observation indicates that the nurse's intervention has been successful?
- A. The mother's nipples are soft to the touch.
- B. The baby swallows after every 5th suck.
- C. The baby's pre- and postfeed weight change is 20 milliliters.
- D. The mother squeezes her nipples during manual expression.
Correct Answer: B
Rationale: Effective sucking indicates improved feeding.