Nokea
Which of the following indicates successful latch-on during a breast-feeding session?
- A. Neonate's lips are flanged outward.
- B. Mother reports sharp pain throughout feeding.
- C. Neonate's cheeks are dimpled.
- D. Mother hears clicking sounds during sucking.
Correct Answer: A
Rationale: Flanged lips indicate a proper latch, ensuring effective milk transfer and preventing nipple trauma.
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A 29-year-old multigravida at 37 weeks' gestation is being treated for severe preeclampsia and has magnesium sulfate infusing at 3 g/hour. The nurse has determined the priority nursing diagnosis to be: risk for central nervous system injury related to hypertension, edema of cerebrum. To maintain safety for this client, the nurse should:
- A. Maintain continuous fetal monitoring.
- B. Encourage family members to remain at bedside.
- C. Assess reflexes, clonus, visual disturbances, and headache.
- D. Monitor maternal liver studies every 4 hours.
Correct Answer: C
Rationale: Monitoring signs of CNS irritability such as reflexes, clonus, visual disturbances, and headache helps detect worsening preeclampsia.
A nurse is counseling a client about the fertility awareness method. Which of the following client statements indicates a need for further teaching?
- A. I will track my basal body temperature daily.
- B. I will monitor my cervical mucus for changes.
- C. I will avoid intercourse during my fertile days.
- D. I can rely on this method even with irregular cycles.
Correct Answer: D
Rationale: The fertility awareness method is less reliable with irregular cycles, as ovulation is harder to predict. The other statements reflect correct understanding, indicating a need for further teaching about cycle regularity.
A multiparous client, 72 hours postpartum, reports a sudden gush of lochia rubra. The nurse should suspect:
- A. Normal involution.
- B. Uterine subinvolution.
- C. Cervical laceration.
- D. Retained placental fragments.
Correct Answer: D
Rationale: A sudden gush of lochia rubra after 72 hours suggests retained placental fragments, which can cause hemorrhage.
A primigravid client in the second stage of labor feels the urge to push. The client has had no analgesia or anesthesia. Anatomically, which of the following would be the best position for the client to assume?
- A. Dorsal recumbent.
- B. Lithotomy.
- C. Hands and knees.
- D. Squatting.
Correct Answer: D
Rationale: Squatting is anatomically optimal for pushing in the second stage as it widens the pelvic outlet, aligns the fetus with the birth canal, and uses gravity to aid descent. Dorsal recumbent and lithotomy positions restrict pelvic mobility, and hands and knees, while helpful for back pain, is less effective for pushing.
When performing an initial assessment of a post-term male neonate weighing 4,000 g (9 lb) who was admitted to the observation nursery after a vaginal delivery with low forceps, the nurse detects Ortolani's sign. Which of the following actions should the nurse do next?
- A. Determine the length of the mother's labor.
- B. Notify the pediatrician immediately.
- C. Keep the neonate under the radiant warmer for 2 hours.
- D. Obtain a blood sample to check for hypoglycemia.
Correct Answer: B
Rationale: Ortolani's sign indicates possible developmental dysplasia of the hip, and immediate notification of the pediatrician is necessary.