Nursing Elites

1. After breastfeeding for 10 minutes at each breast, a new mother calls the nurse to the postpartum room to help change the newborn's diaper. As the mother begins the diaper change, the newborn spits up the breast milk. What action should the nurse implement first?

• A. Wipe away the spit-up and assist the mother with the diaper change.
• B. Sit the newborn upright and burp by rubbing or patting the upper back.
• C. Place the newborn in a position with the head lower than the feet.
• D. Turn the newborn to the side and use bulb suction for the mouth and nares.

Correct answer: B

Rationale: After a newborn spits up breast milk following feeding, the priority action for the nurse is to sit the newborn upright and burp by rubbing or patting the upper back. This position helps release trapped air and reduces the likelihood of further spit-up or aspiration. It is essential to address this first to prevent potential complications and ensure the newborn's comfort and safety.

2. At 39-weeks gestation, a multigravida is having a nonstress test (NST), the fetal heart rate (FHR) has remained non-reactive during 30 minutes of evaluation. Based on this finding, which action should the nurse implement?

• A. Initiate an intravenous infusion.
• B. Observe the FHR pattern for 30 more minutes.
• C. Schedule a biophysical profile.
• D. Place an acoustic stimulator on the abdomen.

Correct answer: D

Rationale: In cases where the fetal heart rate remains non-reactive during an NST, using an acoustic stimulator on the abdomen can help stimulate fetal movement and promote heart rate reactivity. This intervention aims to assess the fetus's well-being and response to external stimuli, which can provide valuable information about fetal health status.

3. A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. Which action should the nurse take?

• A. Obtain blood culture.
• B. Administer penicillin.
• C. Cover lesion with a dressing.
• D. Prepare her for cesarean section.

Correct answer: D

Rationale: Active herpes lesions at the time of delivery increase the risk of neonatal transmission. The most appropriate action in this scenario is to prepare the client for a cesarean section. A cesarean section is often recommended to reduce the risk of neonatal transmission of herpes simplex virus during delivery, especially when active lesions are present. This intervention helps minimize direct contact between the newborn and the infected genital tract secretions, thereby decreasing the risk of transmission.

4. The client at 10 weeks' gestation is palpated with the fundus at 3 fingerbreadths above the pubic symphysis. The client reports nausea, vomiting, and scant dark brown vaginal discharge. What action should the nurse take?

• A. Collect a urine sample for urinalysis.
• B. Measure vital signs.
• C. Recommend bed rest.
• D. Obtain human chorionic gonadotropin levels.

Correct answer: D

Rationale: In a pregnant client with a fundal height greater than expected at 10 weeks and experiencing scant dark brown vaginal discharge, there is a concern for a molar pregnancy. Assessing human chorionic gonadotropin (hCG) levels is crucial in this situation to confirm or rule out this condition.

5. A client who gave birth to a healthy 8-pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant?

• A. Encourage the mother to provide total care for her infant.
• B. Provide privacy so the mother can develop a relationship with the infant.
• C. Encourage the father to provide most of the infant's care during hospitalization.
• D. Meet the mother's physical needs and demonstrate warmth toward the infant.

Correct answer: D

Rationale: Meeting the mother's physical needs and demonstrating warmth toward the infant is essential in creating a supportive environment that fosters bonding between the mother and the newborn. By ensuring the mother's comfort and well-being, the nurse can help promote a positive interaction between the mother and her infant, leading to a stronger emotional connection and bonding.

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