Nokea
A home health nurse is caring for a client who has unilateral mastitis and is experiencing discomfort in the affected breast.
Which of the following instructions should the nurse include?
- A. Tell the client to apply hydrocortisone ointment to the affected area of the breast.
- B. Suggest the client apply warm compresses to the affected breast
- C. Recommend the client avoid wearing a nursing bra until symptoms resolve
- D. Encourage the client to limit oral fluid intake to decrease milk production
Correct Answer: B
Rationale: Applying warm compresses to the affected breast can help relieve pain and promote milk flow, which can aid in resolving the infection. Warmth can help reduce inflammation and make breastfeeding or pumping less painful.
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A nurse is reinforcing teaching with a client who is pregnant and does not consume dairy products.
Which of the following food options should the nurse recommend as the best source of dietary calcium?
- A. 1 cup kale
- B. 1 baked potato
- C. 1 large banana
- D. 1 cup sweet white corn
Correct Answer: A
Rationale: Kale is an excellent non-dairy source of calcium, providing approximately 90 mg per cup when cooked. It's a suitable option for pregnant women who avoid dairy to meet their calcium needs.
A nurse is assisting with the care of a newborn who has neonatal abstinence syndrome.
Which of the following actions should the nurse take first?
- A. Weigh the newborn's wet diaper.
- B. Determine the newborn's respiratory rate.
- C. Auscultate the newborn's bowel sounds.
- D. Swaddle the newborn impretermn blankets.
Correct Answer: B
Rationale: Determining the respiratory rate is critical first, as neonatal abstinence syndrome can cause respiratory distress, requiring immediate intervention for the newborn's safety.
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.
A nurse is assisting with the care of a client who is in labor and has an epidural infusion for pain management. The client's blood pressure is 80/40 mm Hg.
Which of the following actions should the nurse take?
- A. Assist the client to empty her bladder.
- B. Place the client in knee chest position
- C. Administer methylergonovine IM
- D. Give a bolus of lactated Ringer's
Correct Answer: D
Rationale: The client's blood pressure is low (80/40 mm Hg), indicating hypotension, a common side effect of epidural anesthesia during labor. Administering a bolus of intravenous fluids, such as lactated Ringer's solution, is the initial intervention to increase intravascular volume, improving blood pressure and perfusion to vital organs.
A nurse is reinforcing teaching with a client who is at 10 weeks of gestation regarding the purposes of laboratory tests.
Which of the following statements by the client indicates an understanding of the teaching?
- A. White blood cell count is an indicator of anemia.
- B. Urine specific gravity identifies my risk for pregnancy induced hypertension
- C. Platelet count identifies if I am at risk for bleeding
- D. Sedimentation rate checks for signs of cancer
Correct Answer: C
Rationale: Platelet count identifies bleeding risk by assessing clotting ability, a key concern in pregnancy, showing the client understands the test's purpose accurately.