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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Nursing Elites

HESI LPN

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. Monozygotic (MZ) twins share _________ percent of their genes.

Correct answer: A

Rationale: Monozygotic (MZ) twins share 100% of their genes because they originate from the same fertilized egg that splits into two, resulting in identical genetic material for both twins. Choice B (75%) is incorrect as it implies a partial genetic similarity, which is not the case for MZ twins. Choice C (50%) is incorrect as it suggests half of the genes are shared, which is applicable to dizygotic (DZ) twins, not MZ. Choice D (25%) is incorrect as it indicates minimal genetic sharing, which is not true for MZ twins.

3. A premature infant with respiratory distress syndrome (RDS) receives artificial surfactant. How does the nurse explain surfactant therapy to the parents?

Correct answer: A

Rationale: Artificial surfactant can be administered as an adjunct to oxygen and ventilation therapy for premature infants with respiratory distress syndrome (RDS). It helps improve respiratory compliance by aiding in the exchange of oxygen and carbon dioxide until the infant can produce enough surfactant naturally. The correct explanation to the parents would be that surfactant therapy enhances the baby’s lung function by facilitating the exchange of oxygen and carbon dioxide. Choice B is incorrect because surfactant therapy does not affect sedation needs. Choice C is inaccurate as surfactant is not used to reduce episodes of periodic apnea. Choice D is incorrect as surfactant is not administered to fight respiratory tract infections; it specifically targets improving lung function in RDS.

4. What is the most critical action in caring for the newborn immediately after birth?

Correct answer: A

Rationale: The most critical action in caring for the newborn immediately after birth is keeping the airway clear. This is essential to ensure that the newborn can breathe effectively and prevent any respiratory distress. Fostering parent-newborn attachment, although important, is not the most critical action immediately after birth. Drying the newborn and wrapping the infant in a blanket is important for temperature regulation but is not as critical as maintaining a clear airway. Administering eye drops and vitamin K is typically done later and is not the most critical action immediately after birth.

5. A client experiencing preterm labor is being taught about terbutaline by a nurse. Which statement by the client indicates an understanding of the teaching?

Correct answer: A

Rationale: The correct answer is A. Terbutaline is a beta-adrenergic agonist used to stop preterm labor. One of its common side effects is heart palpitations due to its action on beta receptors in the heart. Choices B and C are incorrect because blurred vision and ringing in the ears are not common side effects of terbutaline. Choice D is irrelevant to the side effects of terbutaline.

Similar Questions

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A newborn nursery protocol includes a prescription for ophthalmic erythromycin 5% ointment to both eyes upon a newborn's admission. What action should the nurse take to ensure adequate installation of the ointment?
A client at 30 weeks gestation reports that she has not felt the baby move in the last 24 hours. Concerned, she arrives in a panic at the obstetric clinic where she is immediately sent to the hospital. Which assessment warrants immediate intervention by the nurse?
During the client’s initial prenatal visit, which of the following would indicate a need for further assessment?
On the first postpartum day, the nurse examines the breasts of a new mother. Which condition is the nurse most likely to find?

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