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While caring for the neonate of a human immunodeficiency virus-positive mother, the nurse prepares to administer an ordered hepatitis B intramuscular injection at 4 hours after birth. Which of the following actions should the nurse do first?
- A. Bathe the neonate with an antibacterial soap.
- B. Place the neonate under a radiant warmer.
- C. Wash the injection site with povidone-iodine (Betadine) solution.
- D. Apply clean gloves before administering the medication.
Correct Answer: D
Rationale: Applying clean gloves ensures infection control and safety during the administration of the injection.
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A 25-year-old primiparous client who delivered a viable neonate 2 hours ago has decided to breast-feed her neonate. Which of the following instructions should the nurse address as the highest priority in the teaching plan about preventing nipple soreness?
- A. Keeping plastic liners in the brassiere to keep the nipple drier.
- B. Placing as much of the areola as possible into the baby's mouth.
- C. Smoothly pulling the nipple out of the mouth after 10 minutes.
- D. Removing any remaining milk left on the nipple with a soft washcloth.
Correct Answer: B
Rationale: Proper latch with the areola in the baby's mouth prevents nipple soreness by reducing trauma.
The physician orders oxytocin to be added to the intravenous fluids of a 30-year-old multigravid client at 37 weeks' gestation with twins after vaginal delivery. The nurse should administer the oxytocin after delivery of which of the following?
- A. First placenta.
- B. First twin.
- C. Second placenta.
- D. Second twin.
Correct Answer: C
Rationale: Oxytocin is administered post-delivery of both twins and placentas to promote uterine contraction and prevent postpartum hemorrhage. Administering earlier risks complications with the second twin or placentas.
A multiparous client, 72 hours postpartum, reports a sudden gush of lochia rubra. The nurse should suspect:
- A. Normal involution.
- B. Uterine subinvolution.
- C. Cervical laceration.
- D. Retained placental fragments.
Correct Answer: D
Rationale: A sudden gush of lochia rubra after 72 hours suggests retained placental fragments, which can cause hemorrhage.
A 36-year-old multigravid client is admitted to the hospital with possible ruptured ectopic pregnancy. When obtaining the client's history, which of the following would be most important to identify as a predisposing factor?
- A. Urinary tract infection.
- B. Marijuana use during pregnancy.
- C. Episodes of pelvic inflammatory disease.
- D. Use of estrogen-progestin contraceptives.
Correct Answer: C
Rationale: Pelvic inflammatory disease increases the risk of ectopic pregnancy.
A client asks the nurse about the effectiveness of natural family planning methods. Which of the following responses by the nurse is most accurate?
- A. Natural family planning is as effective as oral contraceptives when used correctly.
- B. The effectiveness of natural family planning depends on consistent monitoring and abstinence during fertile periods.
- C. Natural family planning is less effective than barrier methods likeå®çŸ³
- D. Natural family planning requires no special equipment or cost.
Correct Answer: B
Rationale: The effectiveness of natural family planning depends on consistent monitoring and abstinence during fertile periods. It is less effective than oral contraceptives or barrier methods due to variability in ovulation and user adherence.