the nurse is conducting postpartum teaching with a mother who is breastfeeding her infant when discussing birth control which method should the nurse

HESI RN

Maternity HESI Quizlet

1. The nurse is conducting postpartum teaching with a mother who is breastfeeding her infant. When discussing birth control which method should the nurse recommend to this client as best for her to use in preventing unwanted pregnancy?

A. Breastfeed exclusively at least every 3 to 4 hours.
B. Condoms and contraceptive foam or gel.
C. Rhythm method (natural family planning).
D. Combined estrogen-progesterone oral contraceptives.

Correct answer: B

Rationale: Condoms and contraceptive foam or gel are safe options for breastfeeding mothers and do not affect milk supply.

2. What action should the nurse take if an infant, who was born yesterday weighing 7.5 lbs (3,402 grams), weighs 7 lbs (3,175 grams) today?

A. Inform and assure the mother that this is normal weight loss.
B. Encourage the mother to increase the frequency of breastfeeding.
C. After verifying the accuracy of weight, notify the healthcare provider.
D. Monitor the stool and urine output of the neonate for the last 24 hours.

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to inform and assure the mother that this weight loss is normal. Newborns can lose up to 10% of their birth weight in the first few days after birth, which is attributed to fluid loss and adjustment to life outside the womb. This weight loss is typically regained within the first two weeks of life. It is crucial for the nurse to educate and provide reassurance to the mother about this common occurrence in newborns.

3. The healthcare provider is preparing to give an enema to a laboring client. Which client requires the most caution when carrying out this procedure?

A. A gravida 6, para 5 who is 38 years of age and in early labor.
B. A 37-week primigravida who presents at 100% effacement, 3 cm cervical dilation, and a -1 station.
C. A gravida 2, para 1 who is at 1 cm cervical dilation and a 0 station admitted for induction of labor due to postdates.
D. A 40-week primigravida who is at 6 cm cervical dilation and the presenting part is not engaged.

Correct answer: D

Rationale: The client at 40 weeks of gestation with a 6 cm cervical dilation and a presenting part that is not engaged requires the most caution during an enema procedure. An unengaged presenting part increases the risk of cord prolapse, which can be a serious complication during the procedure. This situation demands careful attention to prevent potential complications and ensure the safety of the client and fetus. Choice A is incorrect as being in early labor does not pose the same level of risk as an unengaged presenting part. Choice B describes a client at 37 weeks with signs of early labor but does not indicate the same level of risk as an unengaged presenting part. Choice C involves a client at 1 cm cervical dilation and a 0 station with no mention of an unengaged presenting part, making it a less critical situation compared to an unengaged presentation, as in Choice D.

4. The nurse is caring for a 2-day old neonate who has not passed meconium and has a swollen abdomen. The healthcare provider reviews the flat plate X-ray of the abdomen and makes a tentative diagnosis of Hirschsprung's disease. Which pathophysiological process is consistent with this neonate's clinical picture?

A. The congenital absence of parasympathetic ganglion cells to large intestine produces no peristalsis.
B. Pyloric obstruction causes reflux and projectile hematemesis.
C. Partial imperforated anal opening limits passage of stools.
D. Peristalsis moving against the intestinal obstruction causing hyperactivity of the bowel.

Correct answer: A

Rationale: Hirschsprung's disease is caused by the absence of parasympathetic ganglion cells in the large intestine, leading to a lack of peristalsis and obstruction.

5. The healthcare provider prescribes Amoxicillin 500mg PO every 8hrs for a child who weighs 22 pounds. The available suspension is labeled Amoxicillin Suspension 250mg/5ml. The recommended maximum dose is 50mg/kg/24hr. How many mL should the nurse administer in a single dose based on the child’s weight?

A. 10mL
B. 15mL
C. 7.5mL
D. 5mL

Correct answer: A

Rationale: To calculate the dose for the child weighing 22 pounds, first convert the weight to kg: 22 lbs ÷ 2.2 = 10 kg. The maximum dose based on weight would be 10 kg × 50 mg/kg/24hr = 500 mg/24hr. Since the medication is prescribed every 8 hours, the dose for each administration would be 500 mg ÷ 3 doses = 166.67 mg. As the available suspension is 250mg/5ml, the nurse should administer 166.67 mg ÷ 250 mg/mL = 0.67 mL per dose. However, since it's not practical to administer a fraction of a milliliter, the nurse should round up to the nearest appropriate dose, which is 10mL.