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A nurse is reinforcing discharge instructions about breastfeeding with a client.
Which of the following statements should the nurse make?
- A. You should feed your baby six times a day.
- B. You should wake your baby at least every 6 hours at night for feedings.
- C. You should recognize that your baby sucking on his hands is a hunger cue.
- D. You should feed your baby for 10 minutes on each breast.
Correct Answer: C
Rationale: Sucking on hands is an early hunger cue, aiding effective feeding by recognizing the baby's needs.
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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. Give a bolus of lactated Ringer's
- B. Assist the client to empty her bladder.
- C. Place the client in knee chest position.
- D. Administer methylergonovine IM.
Correct Answer: A
Rationale: A bolus of lactated Ringer's increases intravascular volume, stabilizing blood pressure caused by epidural-induced vasodilation.
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 nurse my baby for 5 to 10 minutes on each breast.
- B. I will make sure that just the nipple is in my baby's mouth.
- C. I will lay my baby on a pillow at the level of my breast.
- D. I will apply vitamin E oil to my nipples after each feeding.
Correct Answer: C
Rationale: Positioning the baby at breast level with a pillow promotes a comfortable latch and effective feeding.
Nurses' Notes: Newborn lightly swaddled, jittery, weak cry, mottled extremities, acrocyanosis, rapid respirations. History: Gravida 2 Para 2, vaginal birth at 41 weeks, maternal syphilis treated, intermittent cannabis use. Vital Signs: Temp 36°C, HR 132/min, RR 72/min, Weight 4,366 g. Diagnostic Results: Maternal blood type A+, RPR/VDRL negative, urine drug screen positive for marijuana.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Condition: ___ Actions: ___ Parameters: ___
- A. Collect a urine specimen, Monitor the new born after receiving penicillin IM, Reinforce with the parent to feed the newborn, Anticipate a prescription to obtain a capillary blood, Monitor the new born while receiving phototherapy
- B. Hypoglycaemia, Kernicterus, Congenital Syphilis, Neonatal abstinence syndrome
- C. Skin integrity, Bilirubin levels, Respiratory Status, Environmental stimuli, Temperature
Correct Answer: A
Rationale: Jitteriness, weak cry, and large birth weight suggest hypoglycemia. Feeding stabilizes glucose, and capillary blood confirms diagnosis. Monitoring respiratory status and temperature assesses progress.
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. Your baby will wear an electronic bracelet when he is out of your room.
- C. We will match the bracelet on your baby with his footprint record each shift
- D. You should check the identity of individuals who come to remove your baby from the room.
Correct Answer: D
Rationale: Parents should verify the identity of staff to prevent infant abduction, enhancing safety.
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. Suggest the client apply warm compresses to the affected breast
- B. Tell the client to apply hydrocortisone ointment to the affected area of the breast
- C. Encourage the client to limit oral fluid intake to decrease milk production
- D. Recommend the client avoid wearing a nursing bra until symptoms resolve
Correct Answer: A
Rationale: Warm compresses relieve pain, improve circulation, and promote milk flow, aiding in clearing the infection and reducing engorgement.