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A nurse is reinforcing teaching about preventing mastitis with a client who is breastfeeding.
Which of the following instructions should the nurse include?
- A. You should use a breast pump if you plan to return to work.
- B. Cover your breasts immediately after feedings.
- C. Wash your nipples with soap and water daily.
- D. Wear an underwire bra between feedings.
Correct Answer: A
Rationale: Using a breast pump prevents engorgement and maintains milk flow, reducing mastitis risk when returning to work.
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A nurse is reviewing the facility protocol about newborn identification and safety with a new parent.
Which of the following information should the nurse include?
- A. We will scan your baby's identification bracelet each time we check on him.
- B. You should check the identity of individuals who come to remove your baby from the room.
- C. We will match the bracelet on your baby with his footprint record each shift.
- D. Your baby will wear an electronic bracelet when he is out of your room.
Correct Answer: B
Rationale: Parents should verify the identity of anyone taking the baby from the room. This prevents unauthorized individuals from removing the baby, enhancing security and safety.
Nurses' Notes: The newborn is lying in a bassinet, lightly swaddled. Jitteriness observed when disturbed, weak cry, mottled extremities, mild acrocyanosis. Respirations rapid but unlabored. No lethargy, no feedings since birth. Vital Signs: Heart rate: 156/min, Respiratory rate: 64/min, Temperature: 36.1°C (97.0°F), Oxygen saturation: 96% on room air, Blood glucose level: 30 mg/dL.
Complete the diagram by dragging from the choices below to specify: Condition, Actions to Take, Parameters to Monitor (2 Correct). Condition Choices: A. Hypoglycemia, B. Congenital heart defect, C. Neonatal sepsis, D. Neonatal abstinence syndrome. Actions: A. Obtain a capillary blood glucose reading, B. Feed the newborn immediately with breastmilk or formula, C. Administer IV glucose as prescribed, D. Initiate phototherapy, E. Place under a radiant warmer. Parameters: A. Blood glucose levels, B. Respiratory effort, C. Serum bilirubin levels, D. Skin integrity, E. Oxygen saturation.
- A. Hypoglycemia
- B. Obtain a capillary blood glucose reading
- C. Feed the newborn immediately with breastmilk or formula
- D. Blood glucose levels
- E. Respiratory effort
Correct Answer: A,A,B,A,B
Rationale: Low glucose (30 mg/dL) and jitteriness indicate hypoglycemia; feeding and glucose checks address it; glucose and respiratory effort monitor progress.
A nurse is reinforcing teaching with a newly licensed nurse concerning a client on a postpartum unit following a cesarean birth.
Which of the following measures should the nurse include in the instructions to prevent thrombophlebitis?
- A. Have the client ambulate as often as possible.
- B. Apply warm, moist packs to the client's lower legs.
- C. Apply elastic stockings before the client gets out of bed.
- D. Administer NSAIDs every 6 to 8 hours.
Correct Answer: A
Rationale: Ambulation promotes venous return, preventing blood stasis and reducing thrombophlebitis risk after cesarean birth.
A nurse is reinforcing teaching about breastfeeding with a client who is postpartum.
Which of the following statements by the client indicates an understanding of the teaching?
- A. I will make sure that just the nipple is in my baby’s mouth.
- B. I will apply vitamin E oil to my nipples after each feeding.
- C. I will nurse my baby for 5 to 10 minutes on each breast.
- D. I will lay my baby on a pillow at the level of my breast.
Correct Answer: D
Rationale: Laying the baby on a pillow at breast level ensures proper positioning and latch, key to successful breastfeeding.
A nurse is collecting data from a newborn.
The nurse should recognize that which of the following images demonstrates a positive Babinski reflex?
- A. Image showing toes fanning out when the sole is stroked.
- B. Image showing the newborn grasping a finger when the palm is touched.
- C. Image showing the newborn turning the head when the cheek is stroked.
- D. Image showing the newborn making stepping movements when held upright.
Correct Answer: A
Rationale: The image showing toes fanning out when the sole of the foot is stroked demonstrates a positive Babinski reflex, a normal newborn response indicating immature nervous system development.