Nokea
Which of the following would the nurse include in the teaching plan for a primiparous client about the frequency of breast-feeding the neonate during the first few days?
- A. Feeding the neonate whenever he or she cries.
- B. Restricting feedings to 1 to 2 minutes per side.
- C. Feeding the neonate for at least 10 minutes per side.
- D. Maintaining feeding for 20 to 30 minutes per side.
Correct Answer: C
Rationale: Feeding for at least 10 minutes per side ensures adequate milk transfer and stimulation of milk production.
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Two hours after vaginally delivering a viable male neonate under epidural anesthesia, the client with a midline episiotomy ambulates to the bathroom to void. After voiding, the nurse assesses the client's bladder, finding it distended. The nurse interprets this finding based on the understanding that the client's bladder distention is most likely caused by which of the following?
- A. Prolonged first stage of labor.
- B. Urinary tract infection.
- C. Pressure of the uterus on the bladder.
- D. Edema in the lower urinary tract area.
Correct Answer: D
Rationale: Edema in the lower urinary tract, often from delivery trauma or epidural anesthesia, can cause urinary retention and bladder distention.
A newborn is diagnosed with fetal alcohol syndrome. The nurse is teaching this mother what to expect when she goes home with her baby. The nurse determines the mother needs further instruction when she says which of the following?
- A. The way my baby's face looks now will stay that way.'
- B. My baby may be irritable as a newborn.'
- C. I may need some help coping with my newborn.'
- D. My baby will be fine soon after we are home.'
Correct Answer: D
Rationale: FAS is a lifelong condition, and the neonate will not be 'fine' soon after going home, indicating a need for further instruction.
A client asks about the use of a cervical cap for contraception. Which of the following instructions should the nurse provide?
- A. The cervical cap can be left in place for up to 72 hours.
- B. The cervical cap requires a prescription and fitting by a healthcare provider.
- C. The cervical cap is effective without the use of spermicide.
- D. The cervical cap is suitable for women with a history of pelvic infections.
Correct Answer: B
Rationale: The cervical cap requires a prescription and fitting by a healthcare provider to ensure proper size and placement. It can be left in place for up to 48 hours, requires spermicide for effectiveness, and is not ideal for women with pelvic infections due to infection risk.
The nurse is monitoring a primiparous client with postpartum hemorrhage. Which intervention is the highest priority?
- A. Administer oxygen at 2 L/min.
- B. Insert a second IV line.
- C. Massage the fundus vigorously.
- D. Administer methylergonovine as ordered.
Correct Answer: B
Rationale: Inserting a second IV line ensures access for fluid resuscitation, critical in managing hemorrhage.
A client is considering the copper IUD. Which of the following statements by the nurse is accurate?
- A. It requires replacement every 6 months.
- B. It is hormone-free and effective for up to 10 years.
- C. It reduces menstrual bleeding.
- D. It prevents ovulation.
Correct Answer: B
Rationale: The copper IUD is hormone-free and effective for up to 10 years. It does not require replacement every 6 months, may increase menstrual bleeding, and does not prevent ovulation.