a nurse is caring for a client who is experiencing sore nipples from breastfeeding which of the following actions should the nurse take
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Maternity HESI Practice Questions

1. A client is experiencing sore nipples from breastfeeding. Which of the following actions should the nurse take?

Correct answer: B

Rationale: Ensuring the newborn's mouth is wide open before latching is crucial for achieving a proper latch, which can help reduce nipple soreness. Placing a snug dressing on the nipple when not breastfeeding (choice A) can lead to further irritation and hinder healing. Encouraging the client to limit the newborn’s feeding to 10 minutes on each breast (choice C) may not be adequate for effective feeding as infants should feed until they are satisfied. Instructing the client to begin feeding with the most tender nipple (choice D) can worsen the soreness as it may not allow the baby to feed effectively.

2. A nurse is developing an educational program about hemolytic diseases in newborns for a group of newly licensed nurses. Which of the following genetic information should the nurse include in the program as a cause of hemolytic disease?

Correct answer: B

Rationale: The correct answer is B: 'The mother is Rh negative, and the father is Rh positive.' Hemolytic disease of the newborn occurs when an Rh-negative mother carries an Rh-positive fetus, leading to Rh incompatibility. In this scenario, the mother produces antibodies against the Rh antigen present in the fetus, which can result in hemolysis of the fetal red blood cells. Choices A, C, and D do not describe the Rh incompatibility that leads to hemolytic disease in newborns. Therefore, they are incorrect.

3. According to a study conducted in 2013 by Fellman, what affects the chances of having twins?

Correct answer: B

Rationale: The correct answer is B. According to the study by Fellman in 2013, the chances of having twins actually increase with parental age. Choice A is incorrect as the study does not specify a younger age for conceiving to increase the chances of twins. Choice C is incorrect as the frequency of intercourse before conception is not a highlighted factor in the study. Choice D is also incorrect as the study does not discuss the impact of fertility drugs on the likelihood of having twins.

4. A healthcare professional is planning care for a full-term newborn who is receiving phototherapy. Which of the following actions should the healthcare professional include in the plan of care?

Correct answer: B

Rationale: When a newborn is receiving phototherapy, it is important to avoid using lotions or ointments on their skin as these products can lead to skin irritation and burns under the phototherapy lights. Dressing the newborn in lightweight clothing helps ensure proper exposure to the phototherapy lights. Keeping the newborn supine during treatment helps maximize exposure to the light. However, the key consideration in this scenario is to prevent skin irritation and burns by avoiding lotions or ointments.

5. A client who is 24 weeks gestation arrives at the clinic reporting swollen hands. On examination, the nurse notes the client has had a rapid weight gain over six weeks. Which action should the nurse implement next?

Correct answer: B

Rationale: Swollen hands and rapid weight gain could be signs of preeclampsia, so the next step is to check the client's blood pressure. Elevated blood pressure is a key indicator in assessing for preeclampsia in pregnancy. Reviewing the client's previous blood pressures may provide additional context but obtaining the current blood pressure is crucial for immediate assessment. Observing and timing contractions are not relevant in this scenario as the client is not presenting with signs of active labor. Examining for pedal edema is important in assessing for fluid retention, but obtaining the blood pressure takes precedence in this case due to the potential seriousness of preeclampsia.

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