Question 6041)
A nurse is teaching breast care to a client who is breastfeeding. Which client statement indicates that the teaching was effective?
A. "I should air dry my nipples after each feeding."
B. "Mild soap is appropriate for washing my breasts."
C. "My breast pads should be lined with plastic shields."
D. "I will remove my brassiere before I go to bed at night."
Answer: A
Explanation: Air-drying nipples after feeding limits irritation and disruption of skin integrity.
Question 6042) A nurse is teaching breast care to a client who is breastfeeding. Which client statement indicates that the teaching was effective?
A. "I should air dry my nipples after each feeding."
B. "Mild soap is appropriate for washing my breasts."
C. "My breast pads should be lined with plastic shields."
D. "I will remove my brassiere before I go to bed at night."
Answer: A
Explanation: Air-drying nipples after feeding limits irritation and disruption of skin integrity.
Question 6043)
At what time during prenatal development should the nurse expect the greatest fetal weight gain?
A. Third trimester
B. Second trimester
C. First eight weeks
D. Implantation period
Answer: A
Explanation: This is the period in which the fetus stores deposits of fat
Question 6044) What should be included in a plan of care to limit the development of hyperbilirubinemia in the breastfed neonate?
A. Encouraging more frequent breastfeeding during the first 2 days
B. Instituting phototherapy for 30 minutes every 6 hours for 3 days
C. Substituting breastfeeding with formula feeding on the second day
D. Supplementing breastfeeding with glucose-water during the first day
Answer: A
Explanation: More frequent breastfeeding stimulates more frequent evacuation of meconium, thus preventing resorption of bilirubin into the circulatory system.
Question 6045)
At 12 weeks gestation, a client who is Rh negative expels the total products of conception.What is the nursing action after it has been determined that she has not been previously sensitized?
A. Administer RhoGAM within 72 hours.
B. Make certain that RhoGAM is administered at the first clinic visit.
C. Withhold the RhoGAM, because the gestation lasted only 12 weeks.
D. Withhold the RhoGAM,because it is not used after the birth of a stillborn.
Answer: A
Explanation: RhoGAM must be given within 72 hours postpartum if the client has not been sensitized previously, irrespective of the length of the gestation.
Question 6046)
The nurse is differentiating between cephalohematoma and caput succedaneum. What finding is unique to caput succedaneum?
A. Scalp over the area is tender.
B. Edema crosses the suture line.
C. Edema increases during the first day.
D. Scalp over the area becomes echymosed.
Answer: B
Explanation: This is the sign that differentiate between these two conditions, cephalohematoma does not extend beyond the suture line.
Question 6047)
A newborn has an asymmetric Moro reflex. What does a nurse identify as a cause of this problem?
A. Down syndrome
B. Cranial nerve damage
C. Cerebral or cerebellar birth injuries
D. Brachial plexus, calvicular or humeral birth injuries
Answer: D
Explanation: Injury to the brachial plexus,clavicle or humerus during birth prevents abduction and adduction movements of an upper extremity.
Question 6048)
What should the care of a newborn infant whose mother has had untreated syphilis since the second trimester of pregnancy include?
A. Examining for a cleft palate
B. Testing for congenital syphilis
C. Assessing for muscle hypotonicity
D. Observing for maculopapular lesions of the soles
Answer: B
Explanation: Because physical signs of congenital syphilis are difficult to detect at birth, the infant should be screened immediately to determine if treatment is necessary.
Question 6049) The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breastfed. The nurse should provide which instruction to the mother?
A. Feed the newborn less frequently.
B. Continue to breastfeed every 2 to 4 hours.
C. Switch to bottle-feeding the infant for 2 weeks.
D. Stop breastfeeding and switch to bottle-feeding permanently.
Answer: B
Explanation: Hyperbilirubinemia is an elevated serum bilirubin level. At any serum bilirubin level, the appearance of jaundice during the first day of life indicates a pathological process. Early and frequent feeding hastens the excretion of bilirubin. Breastfeeding should be initiated within 2 hours after birth and every 2 to 4 hours thereafter. The infant should not be fed less frequently. Switching to bottle-feeding for 2 weeks or stopping breastfeeding permanently is necessary.
Question 6050)
The nurse notes hypotonia, irritability and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome?
A. Length of 19 inches
B. Abnormal palmar creases
C. Birth weight of 6 lb, 14 oz (3120 g)
D. Head circumference appropriate for gestational age
Answer: B Explanation: Fetal alcohol syndrome, a diagnostic category of fetal alcohol spectrum disorders, is caused by maternal alcohol use during pregnancy. Features of newborns diagnosed with fetal alcohol syndrome includes craniofacial abnormalities, intrauterine growth restriction, cardiac abnormalities, abnormal palmar creases and respiratory distress.
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