Nursing Elites

1. A client who had her first baby three months ago and is breastfeeding her infant tells the nurse that she is currently using the same diaphragm that she used before becoming pregnant. What information should the nurse provide this client?

• A. Use an alternative form of contraception until a new diaphragm is obtained.
• B. After weaning, the diaphragm should be resized.
• C. Avoid intercourse during ovulation until the diaphragm size is reassessed.
• D. If weight gain during pregnancy was no more than 20 pounds, the diaphragm is safe to use.

Correct answer: A

Rationale: The nurse should advise the client to use an alternative form of contraception until a new diaphragm that fits correctly post-pregnancy is obtained. It is essential to ensure proper fit for effective contraception, making it crucial to use an alternative method until the diaphragm is resized.

2. The caregiver observes a mother giving her 11-month-old ferrous sulfate (iron drops), followed by 2 ounces of orange juice. What should the caregiver do next?

• A. Tell the mother to follow the iron drops with infant formula instead of orange juice.
• B. Suggest placing the iron drops in the orange juice and then feeding the infant.
• C. Instruct the mother to feed the infant nothing for 30 minutes after giving the iron drops.
• D. Give the mother positive feedback about the way she administered the medication.

Correct answer: D

Rationale: The high vitamin C content in orange juice aids in the absorption of iron. Providing positive feedback to the mother for administering the iron drops with orange juice is appropriate as it enhances iron absorption, benefiting the infant. Encouraging and acknowledging correct medication administration can help reinforce good practices and build confidence in the caregiver. Choices A, B, and C are incorrect because they do not align with the beneficial practice of administering iron drops with orange juice, which enhances iron absorption. Changing the method of administration based on incorrect assumptions or instructing to withhold feeding after giving iron drops is unnecessary and not evidence-based.

3. A young girl with a fractured radius has a cast applied. As the cast is drying, it is elevated above the level of her heart. Which assessment finding should the healthcare provider be reported to immediately?

• A. Itching sensation under the cast.
• B. Swelling of fingers with brisk capillary refill.
• C. Numbness and inability to move fingers.
• D. Visible bruising above the cast.

Correct answer: C

Rationale: Numbness and inability to move fingers are concerning findings that suggest potential nerve damage or compartment syndrome due to increased pressure within the cast. This requires immediate notification of the healthcare provider to prevent further complications or permanent damage.

4. 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.

5. The nurse is assessing a newborn who was precipitously delivered at 38 weeks' gestation. The newborn is tremulous, tachycardic, and hypertensive. Which assessment action is most important for the nurse to take?

• A. Perform a gestational age assessment.
• B. Obtain a drug screen for cocaine.
• C. Determine reactivity of neonatal reflexes.
• D. Weigh and measure the newborn.

Correct answer: B

Rationale: The correct answer is to obtain a drug screen for cocaine. Tremulousness, tachycardia, and hypertension in a newborn can be signs of neonatal abstinence syndrome, often caused by maternal drug use, such as cocaine. Identifying maternal drug use is crucial for appropriate management and treatment of the newborn.

Similar Questions