a new mother asks the lpnlvn how do i know that my daughter is getting enough breast milk which explanation should the nurse provide
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Nursing Elites

HESI RN

HESI Maternity Test Bank

1. A new mother asks the LPN/LVN, 'How do I know that my daughter is getting enough breast milk?' Which explanation should the nurse provide?

Correct answer: B

Rationale: The correct answer is B. Adequate voiding is a sign that the baby is receiving enough milk. Pale straw-colored urine 6 to 10 times a day indicates proper hydration and nutrition. This is a reliable indicator of adequate breast milk intake for the infant. Choice A is incorrect because weight gain alone may not always indicate sufficient milk intake. Choice C is incorrect because supplementing with bottle milk can interfere with establishing breastfeeding. Choice D is incorrect as it suggests switching to bottle feeding, which is not necessary if the baby is latching and voiding well.

2. During a woman's first prenatal visit, the nurse reviews her health care record, noting a history of chickenpox as a child and syphilis as a teenager. Which action is most important for the nurse to take?

Correct answer: A

Rationale: Obtaining blood and urine for prenatal screens is crucial in identifying any potential infections or conditions that may require monitoring throughout the pregnancy. Screening for infections such as syphilis is essential to ensure appropriate management and prevent adverse outcomes. This action helps in early detection and timely intervention, promoting the health and well-being of both the mother and the developing fetus. The other options, while important during prenatal care, are not as critical as obtaining prenatal screens to assess for any existing infections that could impact the pregnancy.

3. Albumin 25% IV is prescribed for a child with nephrotic syndrome. Which assessment finding indicates to the nurse that the medication is having the desired effect?

Correct answer: D

Rationale: The correct answer is D: Reduction of edema. Albumin helps reduce edema by increasing oncotic pressure, drawing fluid back into the blood vessels. In nephrotic syndrome, there is an abnormal loss of protein in the urine, leading to decreased oncotic pressure and fluid shifting into the interstitial spaces, causing edema. Administering albumin helps restore the oncotic pressure, reducing edema, which is a desirable effect of the medication.

4. Why is complete bedrest necessary for a pregnant client with mitral stenosis Class III?

Correct answer: A

Rationale: Complete bedrest is necessary for a pregnant client with mitral stenosis Class III to reduce the workload on the heart, lower oxygen consumption, and prevent complications associated with cardiac conditions like mitral stenosis. By remaining in bed, the client can help maintain cardiac function and promote a safer pregnancy outcome. Choice B is incorrect as it does not provide a specific reason related to the client's medical condition. Choice C is not addressing the medical necessity of bedrest for this particular client. Choice D is irrelevant and does not explain the importance of bedrest for a pregnant client with mitral stenosis Class III.

5. A 6-month-old child who had a cleft-lip repair has elbow restraints in place. What nursing intervention should the nurse plan to implement?

Correct answer: B

Rationale: Removing restraints one at a time for range of motion exercises prevents muscle stiffness and allows assessment of the skin.

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