AND CORRECT ANSWERS
◉A nurse is caring for a client who is 2 days postpartum, is
breastfeeding, and reports nipple soreness. Which of the following
measures should the nurse suggest to reduce discomfort during
breastfeeding? (SATA)
A. Apply breast milk to the nipples before each feeding.
B. Place breast pads inside the nursing bra.
C. Massage the breasts and nipples prior to feeding.
D. Start breastfeeding with the nipple that is less sore.
E. Change the infant's position on the nipple.. Answer: A D E
◉A nurse is discussing postpartum depression with newly licensed
nurse. Which of the following statements indicates an understanding
of this disorder?
A. "Postpartum depression usually begins 48hr after childbirth."
B. "It's common for client's who have postpartum depression to
exhibit psychotic behavior."
C. "The most common manifestation of postpartum depression is
harming the infant."
,D. "Postpartum depression is most often seen in women who have a
history of depression.". Answer: B. "It's common for client's who
have postpartum depression to exhibit psychotic behavior."
Psychotic behavior is a common finding in clients who have
postpartum psychosis.
◉A nurse is admitting a term newborn following a cesarean birth.
The nurse observes that the newborn's skin is slightly yellow. The
finding indicates the newborn is experiencing a complication related
to which of the following?
A. Maternal/newborn blood group incompatibility
B. Absence of vitamin K
C. Physiologic jaundice
D. Maternal cocaine abuse. Answer: A. Maternal/newborn blood
group incompatibility
Maternal/newborn blood group incompatibility is the most common
form of pathologic jaundice and the jaundice appears within the first
24 hr of life.
◉A nurse is providing teaching to the mother of a newborn born
small for gestational age. Which of the following should the nurse
include as a possible cause of this condition?
A. Placental insufficiency
, B. Preterm delivery
C. Fetal hyperinsulinemia
D. Perinatal asphyxia. Answer: A. Placental insufficiency
Placental insufficiency is a cause of small for gestational age. It can
result from maternal infections, embryonic placental deficiency,
teratogens, or chromosomal abnormalities.
◉A nurse is preparing to administer vitamin K by IM injection to a
newborn. The nurse should administer the medication into which of
the following muscles?
A. Vastus lateralis
B. Ventrogluteal
C. Dorsogluteal
D. Deltoid. Answer: A. Vastus lateralis
The nurse should administer vitamin K, or phytonadione, into the
vastus lateralis muscle in the thigh. This medication prevents and
treats hemorrhagic disease of the newborn, as newborns are born
with vitamin K deficiency.
◉A nurse is providing teaching about comfort measure for breast
engorgement to a client who is postpartum and is breastfeeding.