a nurse is reinforcing postpartum discharge teaching to a client who had no immunity to varicella and was given the varicella vaccine which of the fol
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Nursing Elites

ATI LPN

ATI Maternal Newborn

1. A client is receiving postpartum discharge teaching after being vaccinated for varicella due to lack of immunity. Which statement by the client indicates understanding?

Correct answer: B

Rationale: The correct answer is B because the client needs a second varicella vaccination at the postpartum visit to ensure immunity. Option A is incorrect as it implies a future need for a second vaccination without a clear action plan. Option C is incorrect as the varicella vaccine is primarily for the client's protection, not others. Option D is not the appropriate action as waiting to be tested for immunity delays the necessary second vaccination.

2. A client is in labor, and a nurse observes late decelerations on the electronic fetal monitor. What should the nurse identify as the first action that the registered nurse should take?

Correct answer: A

Rationale: Late decelerations indicate uteroplacental insufficiency. The initial action should be to assist the client into the left-lateral position to optimize maternal blood flow and oxygenation to the fetus, thereby improving uteroplacental blood flow and fetal oxygenation. This position helps reduce pressure on the vena cava, enhancing blood return to the heart and improving circulation to the placenta. Applying a fetal scalp electrode (Choice B) is not the first action indicated for late decelerations. Inserting an IV catheter (Choice C) and performing a vaginal exam (Choice D) are not primary interventions for addressing late decelerations related to uteroplacental insufficiency.

3. A nurse concludes that the parent of a newborn is not showing positive indications of parent-infant bonding. The parent appears very anxious and nervous when asked to bring the newborn to the other parent. Which of the following actions should the nurse use to promote parent-infant bonding?

Correct answer: D

Rationale: Providing reinforcement about infant care when the parent is present can help alleviate anxiety and promote positive parent-infant bonding. By offering guidance and support while the parent is interacting with the newborn, the nurse can help build the parent's confidence and strengthen the bond between the parent and the infant. Choice A is not ideal as it does not address the parent's anxiety and may increase stress levels. Choice B focuses on the parent's emotions without providing direct support for bonding. Choice C is dismissive and does not offer practical assistance in fostering bonding between the parent and the infant.

4. A healthcare professional is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the healthcare professional's priority?

Correct answer: A

Rationale: The correct answer is A: Respiratory distress. Assessing for respiratory distress is the priority when evaluating a newborn after a cesarean delivery. Newborns born via cesarean section are at higher risk for respiratory complications, making it crucial to monitor their breathing and ensure proper oxygenation immediately after birth. Choice B, hypothermia, is important too but assessing breathing takes precedence to ensure adequate oxygen supply. Choices C and D, accidental lacerations and acrocyanosis, are not the immediate priorities following a cesarean delivery.

5. During a teaching session with a client in labor, a nurse is explaining episiotomy. Which of the following information should the nurse include?

Correct answer: C

Rationale: The correct answer is C because an episiotomy is an intentional incision made by the healthcare provider to widen the vaginal opening during delivery. This procedure is performed to facilitate the birth of the baby and prevent uncontrolled tearing of the perineum. It is important for the nurse to educate the client on the purpose and implications of episiotomy to ensure informed decision-making and proper postpartum care. Choice A is incorrect because an episiotomy is not a perineal tear but a deliberate incision. Choice B is incorrect because a fourth-degree episiotomy extending into the rectal area is not a standard practice and can lead to complications. Choice D is incorrect because a mediolateral episiotomy is not universally considered easier to repair than a median episiotomy; the choice of incision type depends on the healthcare provider's preference and clinical situation.

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