Nokea
While assisting a primiparous client with her first breast-feeding session, which of the following actions should the nurse instruct the mother to do to stimulate the neonate to open the mouth and grasp the nipple?
- A. Pull down gently on the neonate's chin and insert the nipple.
- B. Squeeze both of the neonate's cheeks simultaneously.
- C. Place the nipple into the neonate's mouth on top of the tongue.
- D. Brush the neonate's lips lightly with the nipple.
Correct Answer: D
Rationale: Brushing the neonate's lips with the nipple stimulates the rooting reflex, encouraging the mouth to open.
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A neonate delivered at 40 weeks' gestation admitted to the nursery is found to be hypoglycemic. At 4 hours of age, the neonate appears pale and his pulse oximeter is reading 75 %. The nurse should:
- A. Increase the I.V. rate.
- B. Provide supplemental oxygen.
- C. Record the finding on the chart and repeat the reading in 30 minutes.
- D. Wrap the neonate to increase body temperature.
Correct Answer: B
Rationale: A pulse oximetry reading of 75% indicates hypoxemia, and providing supplemental oxygen is the priority.
The nurse is making clinical rounds on a group of clients in a newborn nursery. Which infant is at greatest risk of developing respiratory distress syndrome (RDS)?
- A. A neonate born at 36 weeks' gestation.
- B. A neonate born by Cesarean section.
- C. A neonate experiencing apneic episodes.
- D. A neonate who is 42 weeks' gestation.
Correct Answer: C
Rationale: A neonate experiencing apneic episodes is at greatest risk for RDS due to compromised respiratory function.
A postpartum client delivered 6 hours ago without anesthesia and just voided 100 mL. The nurse palpates the fundus 2 fingerbreadths above the umbilicus and off to the right side. What should the nurse do next?
- A. Administer ibuprofen (Motrin).
- B. Reassess in 1 hour.
- C. Catheterize the client.
- D. Administer an I.V. bolus of 500 mL to rehydrate per policy.
Correct Answer: C
Rationale: A deviated fundus and small void suggest bladder distention, requiring catheterization to empty the bladder.
When developing the plan of care for a primiparous client during the first 12 hours after vaginal delivery, which of the following concerns of the client should be the nurse's primary focus of care?
- A. The neonate.
- B. The family.
- C. The client's own comfort.
- D. The client's significant other.
Correct Answer: C
Rationale: In the first 12 hours postpartum, the nurse's primary focus is the client's physical and emotional comfort to promote recovery and prevent complications.
A client asks about the benefits of male condoms. Which of the following would the nurse include?
- A. They are 100% effective in preventing pregnancy.
- B. They provide some protection against STIs.
- C. They can be reused if undamaged.
- D. They require a prescription.
Correct Answer: B
Rationale: Male condoms provide some protection against STIs, which is a key benefit. They are not 100% effective, cannot be reused, and do not require a prescription.