Nursing Elites

1. A breastfeeding mother is experiencing nipple pain. What should the nurse instruct her to do?

• A. Use soap and water to clean her nipples
• B. Apply warm compresses to her breasts
• C. Ensure the baby is latching on properly
• D. Limit breastfeeding to every 4 hours

Correct answer: C

Rationale: When a breastfeeding mother experiences nipple pain, ensuring the baby latches on properly is essential. Proper latch-on technique can help prevent and alleviate nipple pain by ensuring the baby is effectively extracting milk and not causing undue pressure or friction on the nipple. This guidance can promote a more comfortable breastfeeding experience for the mother and improve milk transfer for the baby.

2. The client is being taught about perineal care postpartum. Which instruction should the client receive?

• A. Use ice packs to reduce swelling for the first 24 hours.
• B. Apply heat packs immediately after birth to reduce pain.
• C. Avoid using a peri-bottle to cleanse the perineum.
• D. Use tampons to absorb lochia discharge.

Correct answer: A

Rationale: The correct instruction for the client postpartum is to use ice packs to reduce swelling for the first 24 hours. This helps alleviate discomfort and promote healing. Applying heat packs immediately after birth is not recommended as they can increase swelling. A peri-bottle is advised for cleansing the perineum, not to be avoided. Tampons should not be used to absorb lochia discharge as they can increase the risk of infection. Therefore, the use of ice packs is the most appropriate and beneficial instruction for perineal care postpartum.

3. Mr. Lopez has a 7-year-old son with growth hormone (GH) deficiency. He shares with the nurse the desire of his son to play ball games. However, his wife feels the child will be in danger since he is smaller than the other children. In planning anticipatory guidance for these parents, the nurse should keep in mind which of the following?

• A. The child should be allowed to play because doing so can foster healthy self-esteem
• B. The risk for fractures is increased because GH deficiency results in fragile bones
• C. Activity could aggravate insulin sensitivity, causing hyperglycemia
• D. Activity would aggravate the child's joints, already overtasked by obesity

Correct answer: A

Rationale: Children with GH deficiency may face challenges due to their size, but it is important to encourage their participation in activities like playing ball games to promote healthy self-esteem. Allowing the child to play can help in building confidence and a sense of accomplishment, which are essential for their overall well-being.

4. Which of the following signs would you expect to see in a child with respiratory failure?

• A. Slow, irregular breathing
• B. Flushed skin
• C. Strong cry
• D. Unconsciousness

Correct answer: A

Rationale: In a child with respiratory failure, slow, irregular breathing is a common sign. Respiratory failure impairs the ability to exchange oxygen and carbon dioxide efficiently, leading to altered breathing patterns. Flushed skin, a strong cry, or unconsciousness may not be specific signs of respiratory failure and could be indicative of other conditions. Flushed skin may be a sign of fever or increased blood flow, a strong cry may indicate pain or distress, and unconsciousness can have various causes beyond respiratory failure.

5. What action should you take if a newborn's heart rate is 50 beats/min?

• A. Begin chest compressions.
• B. Reassess in 30 seconds.
• C. Administer blow-by oxygen.
• D. Start positive-pressure ventilations.

Correct answer: D

Rationale: If a newborn's heart rate is below 60 beats per minute, the appropriate action is to start positive-pressure ventilations. Ventilations help deliver oxygen to the newborn's body and support respiratory function, which is critical in cases of bradycardia. Chest compressions are not recommended until the heart rate is below 60 despite adequate ventilation. Reassessment is essential but not the immediate action required in this scenario. Administering blow-by oxygen alone may not effectively address the underlying cause of bradycardia, making positive-pressure ventilations the priority intervention in this case.

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