Contemporary Maternal Newborn Nursing 7th Edition by Patricia W. Ladewig Test Bank

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Contemporary Maternal Newborn Nursing 7th Edition by Patricia W. Ladewig Test Bank

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Contemporary Maternal Newborn Nursing 7th Edition by Patricia W. Ladewig Test Bank

Chapter 02_LO 01_Q01

Why is it important for the nurse to understand the type of family that a client comes from? Select all that apply.

  1. Family structure can influence finances and the ability to purchase nutritious foods.
  2. Many types of families exist, and it is important to address the persons who hold power within the family.
  3. The nurse can anticipate which problems a client will experience based on the type of family the client has.
  4. Understanding if the clients family is nuclear or blended will help the nurse teach the client the appropriate information.
  5. The values of the family will be predictable if the nurse knows what type of family the client is a part of.

Correct Answers: 1, 2

Rationale:

  1. Dual-career/dual-earner families tend to have more stable finances, while single-parent families tend to have lower incomes. Nutrition impacts fetal growth and development, and nutritious foods tend to be more costly than nutrient-poor or junk food. Thus understanding the type of family can help the nurse determine the best education for the client.
  2. Understanding the family power is important so that the nurse will address the appropriate person(s). This will facilitate effective communication, as the nurse will be perceived as respectful of the family.
  3. Each client and family must be assessed as individuals, without making assumptions. Although generalities can be drawn based on the type of family that a client comes from or currently is part of, stereotypes must be avoided.
  4. Each client and family must be assessed as individuals, without making assumptions. Although generalities can be drawn based on the type of family that a client comes from or currently is part of, stereotypes must be avoided.
  5. Each client and family must be assessed as individuals, without making assumptions. Although generalities can be drawn based on the type of family that a client comes from or currently is part of, stereotypes must be avoided.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Assessment

Learning Outcome: 2.1 Describe how family type can influence nursing care of the childbearing family.

 

Chapter 02_LO2 _Q02

The nurse is preparing a community presentation on family development. Which of the following statements should the nurse include?

  1. The youngest childs age determines the familys current stage.
  2. A family does not experience overlapping of stages.
  3. Family development ends when the youngest child leaves home.
  4. The stages describe the familys progression over time.

Answer: 4

Rationale:

  1. The oldest childs age is the marker for which stage the family is in, except for the two last stages, which occur after the children have left home.
  2. Families with more than one child can experience multiple stages simultaneously.
  3. Families with more than one child can experience multiple stages simultaneously.
  4. Family development stages describe the changes and adaptations that a family goes through over time as children are added to the family.

 

Assessment

Health Promotion and Maintenance

Application

Learning Outcome 2.2  Explain the changes that a childbearing family will undergo based on the developmental tasks to be completed.

 

Chapter 02_LO03 _Q03

The nurse is preparing to assess the development of a family new to the clinic. The nurse understands that the primary use of a family assessment tool is to:

  1. Obtain a comprehensive medical history of family members.
  2. Determine which clinic the client should be referred to.
  3. Predict how a family will likely change with the addition of children.
  4. Understand the physical, emotional, and spiritual needs of members.

Correct Answer: 4

Rationale:

  1. The focus of a family assessment is the family as one entity. Health of the family is one area that is explored using a family assessment tool.
  2. The family assessment tool facilitates understanding of the physical, emotional, and spiritual needs of members. Although referrals might take place as a result of the family assessment findings, understanding of the family is the primary reason the tool is used.
  3. The family assessment tool facilitates understanding of the physical, emotional, and spiritual needs of members. Family development models help predict how a family will likely change with the addition of children.
  4. This is the main reason for using a family assessment tool.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Assessment

Learning Outcome: 2.3 Identify information that would be useful to collect when performing a family assessment.

 

 

 

 

Chapter 02_LO 04_Q04

A laboring client has been very quiet during labor, and has made no noise during contractions during the past four hours. The client is of Chinese descent. The nurse understands that this indicates that the client:

  1. Believes pain should be endured and not expressed.
  2. Is not in the active phase of labor yet.
  3. Will not need pain medication during her hospitalization.
  4. Has been abused by her husband and is afraid to verbalize fear.

Correct Answer: 1

Rationale:

  1. This is a common traditional Chinese belief.
  2. Because it is a common traditional Chinese belief to not express pain verbally, the nurse must assess for the progression of labor in other ways.
  3. Although it is a common traditional Chinese belief to not express pain verbally, the assumption cannot be made that no pain relief medication will be needed either during the labor and birth or the postpartum period.
  4. It is a common traditional Chinese belief to not express pain verbally, and does not indicate domestic abuse.

Cognitive level: Analysis

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Diagnosis

Learning Outcome: 2.4 Integrate the prevalent cultural norms of a family that affect childbearing and child rearing when providing care to that family.

 

 

Chapter 02_LO 04_Q05

 

A woman of Korean descent has just given birth to a son. Her partner wishes to give her sips of hot broth from a thermos he brought from home. The client has refused your offer of ice chips or other cold drinks. The nurse should:

  1. Explain to the client that she can have the broth if she will also drink cold water or juice.
  2. Encourage the partner to feed the client sips of broth. Ask if the client would like you to bring her some warm water to drink as well.
  3. Explain to the couple that food cant be brought from home, but that the nurse will make hot broth for the client.

 

  1. Encourage the client to have the broth, after the nurse takes it to the kitchen and boils it first.

 

Correct Answer: 2

Rationale:

  1. Explaining to the client that she can have broth if she will drink cold water or juice first does not show cultural sensitivity and does not respect the clients beliefs.
  2. Encouraging the partner to feed the client sips of broth and asking if the client would like you to bring her some warm water to drink as well is an approach that shows cultural sensitivity. The equilibrium model of health, based on the concept of balance between light and dark, heat and cold, is the foundation for this belief and practice.
  3. Explaining to the couple that the hospital does not allow food brought from home but that you will make hot broth for them is an incorrect response.
  4. Encouraging the client to have broth after you take it the kitchen and boil it first is an incorrect response because boiling first would make the broth too hot to drink.

Nursing Process: Intervention

Category of Client Need: Health Promotion: Growth and Development

Cognitive Level: Application

Learning Outcome: 2.4 Integrate the prevalent cultural norms of a family that affect childbearing and child rearing when providing care to that family.

 

 

Chapter 02_LO 05_Q06

The nurse works in a facility that cares for clients from a broad range of racial, ethnic, cultural, and religious backgrounds. Which statement should the nurse include in a presentation for nurses new to the facility on the client population of the facility?

  1. Our clients come from a broad range of backgrounds, but we have a good interpreter service.
  2. Many of our clients come from backgrounds different from your own, but it doesnt cause problems for the nurses.
  3. Because most of the doctors are bilingual, we dont have to deal with the differences in cultural backgrounds of our clients.
  4. Understanding the common values and health practices of our diverse clients will facilitate better care and health outcomes.

Correct Answer: 4

Rationale:

  1. The role of a foreign language interpreter is to facilitate communication. The interpreter might or might not be able to interpret the cultural practices of clients. An example is a Spanish interpreter: The interpreter might be from Spain, but interprets language for clients from Guatemala and Nicaragua, countries about which the interpreter might know virtually nothing.
  2. Racial, ethnic, cultural, and religious backgrounds of clients have significant implications for how they perceive health, illness, and health care. It is important for nurses to understand the backgrounds of the client population that attend that facility.
  3. Bilingual physicians, like all physicians, have very busy schedules, and often do not understand nursing care. It is the responsibility of the nurse to become familiar with the backgrounds of the client population.
  4. Because of the implications for care based on cultural background, it is important for nurses to understand the backgrounds of the client population that attend the facility.

Cognitive level: Analysis

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Planning

Learning Outcome: 2.5 Explain the importance of cultural competency in providing nursing care to the childbearing family.

 

 

Chapter 02_LO 05_Q07

The nurse manager in a hospital with a large immigrant population is planning an in-service. The nurse manager is aware of how ethnocentrism affects nursing care. Which statement should the nurse manager include? The belief that ones own values and beliefs are the only or the best values:

  1. Means that newcomers to the United States should adopt U.S. norms and values.
  2. Can create barriers to communication through misunderstanding.
  3. Leads to an expectation that all clients will exhibit pain the same way.
  4. Improves the quality of care provided to culturally diverse client bases.

Answer: 2

Rationale:

  1. Although acculturation involves adoption of some of the majority cultures practices and beliefs, each cultural group will continue to hold and express its own set of values and beliefs.
  2. Ethnocentrism is the conviction that ones own values and beliefs either are the only ones that exist, or are the best. When the nurse assumes that a client has the same values and beliefs as the nurse, misunderstanding will frequently occur, which in turn can negatively impact nurseclient communication.
  3. Expression of pain is one area that varies greatly from one culture to another.
  4. The belief that ones own values and beliefs are the best will not improve the quality of care provided to culturally diverse client bases.

Cognitive Level: Application

Category of Client Need: Psychosocial Integrity

Nursing Process: Planning

Learning Outcome 2.5  Explain the importance of cultural competency in providing nursing care to the childbearing family.

 

 

Chapter 02_LO 05_Q08

 

When preparing to teach a culturally diverse group of childbearing families about hospital birthing options, in order to be culturally competent, the nurse should:

  1. Understand that the families have the same values as the nurse.
  2. Teach the families how childbearing takes place in the United States.
  3. Insist that the clients answer questions instead of their husbands.
  4. Learn about the cultural groups that are likely to attend the class.

Answer: 4

Rationale:

  1. Assuming that the families have the same values is ethnocentrism.
  2. Although it is important to explain health care during pregnancy and childbearing, this is not the top priority.
  3. The husbands answering questions might be a cultural norm, and insisting that the client answer could decrease the familys trust in the health care system.
  4. Cultural competence is the development of skills and knowledge necessary to appreciate, understand, and work with individuals from other cultures than the culture of the nurse. Through gaining knowledge of the cultures that are likely to be encountered professionally, the nurse is able to understand the aspects of the clients culture that might impact how care should best be given to be accepted by the client.

Cognitive Level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Planning

Learning Outcome 2.5 Explain the importance of cultural competency in providing nursing care to the childbearing family.

 

 

Chapter 02_LO 06_Q09

The nurse is admitting a Mexican woman scheduled for a cholecystectomy. The nurse uses a cultural assessment tool during the admission. Which question would be most important for the nurse to ask?

  1. What other treatments have you used for your abdominal pain?
  2. What is your country of origin; where were you were born?
  3. When you talk to family members, how close do you stand?
  4. How would you describe your role within your family?

Correct Answer: 1

Rationale:

  1. This question is most important because some traditional or folk remedies include the use of herbs. Because some herbs have medication interactions, this physiologic question is imperative to ask.
  2. Although this information is helpful, it is not a physiological issue. Asking about other treatments is a higher priority.
  3. Although understanding the clients perception of appropriate personal space is helpful, it is not a physiological issue. Asking about other treatments is a higher priority.
  4. Although understanding the clients family roles is helpful, it is not a physiological issue. Asking about other treatments is a higher priority.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Planning

Learning Outcome: 2.6 Interpret the information collected from a cultural assessment to provide culturally sensitive care.

 

Chapter 02_LO 07_Q10

The Labor and Delivery nurse is caring for a laboring client who has asked for a priest to visit her during labor. The clients mother died during childbirth, and although there are no complications during the clients pregnancy, she is fearful of her own death during labor. What is the best response of the nurse?

  1. Nothing is going to happen to you. Well take very good care of you during your birth.
  2. Would you like to have an epidural so that you wont feel the pain of the contractions?
  3. The priest wont be able to prevent complications, and might get in the way of your providers.
  4. Would you like me to contact your parish or our hospital chaplain to come see you?

Correct Answer: 4

Rationale:

  1. Avoid statements of false reassurance, as there are no guarantees in the outcomes during health care. Using these statements shuts down effective communication, as the clients concern is downplayed.
  2. The clients expressed concern is not about pain, it is a fear of death and a desire to see a priest. Address the clients concerns directly.
  3. Although this statement is true, it is not therapeutic. It downplays the clients concerns, and will shut down effective communication. Address the concerns the client expresses.
  4. When the client states she wants to see a priest, the nurse should attempt to make arrangements for this visit to occur in a timely manner. Most hospitals have a chaplaincy department that can provide assistance in obtaining the services of a wide variety of religious leaders. Depending on the day of the week and the time of day, the clients own home parish church might be able to provide a priest for pastoral care at the bedside.

Cognitive level: Application

Category of Client Need: Psychosocial Integrity

Nursing Process: Planning

Learning Outcome: 2.7 Identify ways a nurse might accommodate the religious rituals and practices of the childbearing family.

 

Chapter 02_LO 08_Q11

The nurse is assessing a client who reports seeing an acupuncturist on a weekly basis to treat back pain. The nurse understands that acupuncture is an example of:

  1. A risky practice without evidence of efficacy.
  2. Folk remedy use.
  3. Complementary therapy.
  4. Alternative therapy.

Correct Answer: 3

Rationale:

  1. Acupuncture has been a traditional Chinese medicine for over 3,000 years. Good evidence is available on the efficacy of acupuncture for treatment of chronic pain.
  2. A folk remedy is a practice of a cultural group that either has no evidence to support efficacy or has been found not to have an effect. Acupuncture has been a traditional Chinese medicine for over 3,000 years.
  3. Acupuncture is a therapy that is used in conjunction with conventional medical treatment, and therefore is an example of a complementary therapy.
  4. An alternative therapy is usually considered a substance or procedure that is used in place of conventional medicine. Acupuncture is categorized as a complementary therapy.

Cognitive level: Application

Category of Client Need: Physiologic Integrity

Nursing Process: Diagnosis

Learning Outcome: 2.8 Distinguish between complementary and alternative therapies.

 

Chapter 02_LO 08_Q12

 

The client states, I am using homeopathic remedies to help with my morning sickness. The nurse understands that the client is utilizing:

  1. A complementary therapy.
  2. An alternative therapy.
  3. Traditional Chinese medicine.
  4. Naturopathy.

Answer: 1

Rationale:

  1. A complementary therapy is that which is an adjunct to traditional medical treatment, and has been shown through rigorous scientific testing to be reliable.
  2. Alternative therapies are those that have not undergone rigorous scientific testing.
  3. Traditional Chinese medicine includes acupuncture and herbology.
  4. Naturopathy is an eclectic combination of nutrition, botanical medicine, homeopathy, acupuncture, hydrotherapy, and physiotherapy.

Cognitive Level: Analysis

Category of Client Need: Physiologic Integrity

Nursing Process: Assessment

Learning Outcome 2.8 Distinguish between complementary and alternative therapies.

 

Chapter 02_LO09_Q13

The client pregnant with her first child reports that her husband wants her to visit a homeopath for help with her nausea and vomiting. The client asks what the nurses opinion of homeopathy is. The best response by the nurse is:

  1. Homeopathy is unproven and potentially dangerous. Avoid using homeopathic remedies.
  2. The FDA has approved homeopathic remedies, and practitioners undergo education and certification.
  3. I cant give you advice about what alternatives to try. Go online and do some research to get information.
  4. Homeopathy is the same as herbal remedies. Some are safe during pregnancy and some are not.

Correct Answer: 2

Rationale:

  1. Homeopathic remedies are not dangerous. Homeopathic remedies are FDA-approved, and have been proven to be effective in treating a wide range of chronic and acute illnesses and conditions.
  2. Homeopathic remedies are FDA-approved, and have been proven to be effective in treating a wide range of chronic and acute illnesses and conditions.
  3. It is appropriate for the nurse to provide factual information to educate a client who has asked a question. Not all clients have access to computers, nor do they know how to do an internet search.
  4. Herbalism and homeopathy are not the same. Herbs are available in many stores and preparations; some have been proven to be dangerous during pregnancy. Homeopathy is a system of like curing like, in which the symptom being treated would be a symptom of taking too much of the substance in a non-homeopathic form.

Cognitive level: Analysis

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Implementation

Learning Outcome: 2.9 Describe the benefits and risks of the various complementary and alternative therapies to the childbearing family.

 

 

Chapter 02_LO09_Q14

 

Complementary and alternative therapies have many benefits for the childbearing family and others. However, many of these remedies have associated risks. Which of the following situations would be considered risks? Select all that apply.

  1. Getting a massage from a licensed massage therapist for back pain, prescribed by the primary caregiver
  2. Trying out a homeopathic medicine from a friend to reduce swelling in the legs
  3. Getting a chiropractic treatment for low back pain due to discomforts of pregnancy without telling the primary health care provider
  4. Taking an herbal preparation suggested by a health food store worker for treatment of leg pain
  5. Joining a group that practices tai chi weekly to help with physical fitness and movement

Correct Answers: 2, 3, 4

 

Rationale:

  1. Getting a massage from a licensed massage therapist for back pain, prescribed by the primary caregiver, is a perfectly good use of complementary therapies.

 

  1. Trying out a homeopathic medicine from a friend to reduce swelling in your legs is a risk factor when considering these therapies. Lack of standardization, lack of regulation and research to substantiate their safety and effectiveness, and inadequate training and certification of some healers make some therapies risky.

 

  1. Getting a chiropractic treatment for low back pain due to discomforts of pregnancy without telling the primary health care provider is a risk factor when considering these therapies. Lack of standardization, lack of regulation and research to substantiate their safety and effectiveness, and inadequate training and certification of some healers make some therapies risky.

 

  1. Taking an herbal preparation suggested by a health food store worker for treatment of leg pain is a risk factor when considering these therapies. Lack of standardization, lack of regulation and research to substantiate their safety and effectiveness, and inadequate training and certification of some healers make some therapies risky.

 

  1. Joining a group that practices tai chi weekly to help with physical fitness and movement is a perfectly good use of complementary therapies.

Nursing Process: Assessment

Category of Client Need: Safe, Effective Care Environment: Management of Care

Cognitive Level: Analysis

Learning Outcome: 2.9 Describe the benefits and risks of the various complementary and alternative therapies to the childbearing family.

 

 

Chapter 02_LO 10_Q15

The Labor and Delivery unit nurse manager is incorporating complementary and alternative therapies into the units policies and procedures. Which statement should the nurse manager make to the nursing staff during an in-service educational presentation?

  1. Policies have been developed for using massage and aromatherapy.
  2. When clients ask questions you dont know, tell them to look online.
  3. Because herbs are dangerous during pregnancy, we will not use them.
  4. Be sure to ask clients what alternative therapies they have used.

Correct Answer: 1

Rationale:

  1. The development of written policies and procedures facilitates safe nursing practice, which in turn promotes client safety.
  2. Online information can vary in its accuracy. Reputable sources (electronic or print) should be recommended for further client education.
  3. This statement is false. Many herbs can be safely used during pregnancy.
  4. What the client has used in the past does not predict what she is open to using at present. It is more important to develop written policies and procedures.

Cognitive level: Application

Category of Client Need: Physiological Integrity

Nursing Process: Planning

Learning Outcome: 2.10 Formulate nursing care within the nurse practice act and with the informed consent of the client when using appropriate complementary therapies with childbearing families.

 

Chapter 16_LO01_Q01

The nurse is supervising care in the Emergency Department. Which situation most requires an intervention?

  1. Moderate vaginal bleeding at 36 weeks gestation; client has an IV of lactated Ringers solution running at 125 mL/hour.
  2. Spotting of pinkish-brown discharge at 6 weeks gestation and abdominal cramping; ultrasound scheduled in one hour
  3. Bright red bleeding with clots at 32 weeks gestation; pulse = 110, blood pressure 90/50, respirations = 20
  4. Dark red bleeding at 30 weeks gestation with normal vital signs; client reports an absence of fetal movement.

Correct Answer: 3

Rationale:

  1. Bleeding in the third trimester is usually a placenta previa or placental abruption. Blood loss can be heavy and rapid, so having an IV stabilizes the clients vascular volume.
  2. Bleeding in the first trimester can be indicative of spontaneous abortion beginning or of an ectopic pregnancy. An ultrasound will diagnose which situation is occurring, and will determine care. Because this client is very early in the pregnancy, and only experiencing spotting, it is not appropriate to have an IV at this time.
  3. Bleeding in the third trimester is usually a placenta previa or placental abruption. Blood loss can be heavy and rapid. This client has a low blood pressure with an increased pulse rate, which indicates hypovolemic shock, which can be fatal to the mother and therefore the baby. Both lives are at risk in this situation. Since there is no information given that the client has an IV started, this client is the least stable, and therefore the highest priority.
  4. Watery, dark red bleeding in the third trimester can indicate placental abruption with ruptured membranes. Normal vital signs indicate a normal vascular volume. A lack of fetal movement could indicate fetal hypoxia or fetal demise. The fetus is at greatest risk in this situation; the mother is stable.

Cognitive level: Analysis

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Assessment

Learning Outcome: 16-1 Relate the etiology, medical therapy, and cultural perspectives to community-based and hospital-based nursing care management of women with a bleeding problem associated with pregnancy.

 

Chapter 16_LO02 _Q02

The prenatal clinic nurse is caring for a client with hyperemesis gravidarum at 14 weeks gestation. The vital signs are: blood pressure 95/48, pulse 114, respirations 24. Which order should the nurse implement first?

  1. Weigh the client.
  2. Give 1 liter of lactated Ringers solution IV.
  3. Administer 30 ml Maalox (magnesium hydroxide) orally.
  4. Encourage clear liquids orally.

Correct Answer: 2

Rationale:

  1. Weighing the client provides information on weight gain or loss, but is not the top priority in a client with excessive vomiting during pregnancy. The vital signs indicate hypovolemia. The client needs IV fluids.
  2. The vital signs indicate hypovolemia. Giving this client a liter of lactated Ringers solution intravenously will re-establish vascular volume and bring the blood pressure up, and the pulse and respiratory rate down.
  3. The vital signs indicate hypovolemia. There is no indication that the client has dyspepsia. The client needs IV fluids.
  4. The client needs IV fluids, because the vital signs indicating hypovolemia. Oral fluids are not likely to be tolerated well by a client with hyperemesis. Lack of tolerance of oral fluids through excessive vomiting is what has led to the hypovolemia.

Cognitive level: Analysis

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Planning

Learning Outcome: 16-2 Describe the maternal and fetal/neonatal risks and medical therapy in community-based and hospital-based nursing care management of the woman with hyperemesis gravidarum.

 

Chapter 16_LO03 _Q03

The nurse on the high-risk antepartal unit has received shift change report. Which client should the nurse see first?

  1. Primip at 26 weeks with prolonged premature rupture of membranes experiencing chills
  2. Multip at 28 weeks with premature rupture of membranes reporting leakage of clear vaginal fluid
  3. Primip at 30 weeks with premature rupture of membranes due for a betamethasone injection
  4. Multip at 32 weeks with prolonged premature rupture of membranes and a hemoglobin of 11.0

Correct Answer: 1

Rationale:

  1. Chills indicate fever, which in turn indicates infection. Prolonged premature rupture of membranes increases the risk of maternal infection, specifically chorioamnionitis. Intrauterine infection can be life-threatening to the fetus or to a neonate. This client requires immediate intervention, including contacting the physician.
  2. Premature rupture of membranes is the leakage of amniotic fluid; continued leaking of clear fluid does not indicate the development of further complications.
  3. Scheduled medications are important, but when a client is experiencing complications, medications are less important.
  4. Although this client has prolonged premature rupture of membranes, there is no indication of any further complications. This client is a low priority.

Cognitive level: Analysis

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Planning

Learning Outcome: 16-3 Delineate the nursing care needs of a woman experiencing premature rupture of the membranes or preterm labor.

 

Chapter 16_LO03 _Q04

A woman is being treated for preterm labor with magnesium sulfate. The nurse is concerned that the client is experiencing early drug toxicity. What assessment finding by the nurse indicates early magnesium sulfate toxicity?

  1. Patellar reflexes are weak or absent.
  2. complaints by the client of feeling flushed and warm
  3. Respiratory rate of 16
  4. Fetal heart rate of 120

Answer: 1

Rationale:

  1. Early signs of magnesium sulfate toxicity are related to a decrease in deep tendon reflexes.
  2. The peripheral vasodilation will cause flushing and a feeling of warmth; this is a side effect, not a toxic effect.
  3. Late signs of toxicity are a respiratory rate less than 12, urine output less than 30 cc/hr, and confusion.
  4. Magnesium typically has no effect on fetal heart rate.

Cognitive Level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Assessment

Learning Outcome 16-3 Delineate the nursing care needs of a woman experiencing premature rupture of the membranes or preterm labor.

 

Chapter 16_LO03 _Q05

A client has pre-eclampsia. She is 36 weeks pregnant, and comes to the high-risk screening center for a contraction stress test. The nurse should explain to the client that the contraction stress test is being done to determine:

  1. What effect her hypertension has had on the fetus.
  2. If the fetus will be able to tolerate labor.
  3. If fetal movement increases with contractions.
  4. What effect contractions will have on her blood pressure.

Answer: 2

Rationale:

  1. The fetal heart rate response to movement is assessed in a non-stress test.
  2. Contraction stress tests are performed to assess the ability of the fetus to tolerate labor.
  3. With contractions, the nurse is assessing for a heart rate response, not movement.
  4. The effect of contractions on blood pressure would be noted, but this is not the purpose.

Cognitive Level: Application

Category of Learning: Health Promotion and Maintenance

Nursing Process: Implementation

Learning Outcome 16-3 Delineate the nursing care needs of a woman experiencing premature rupture of the membranes or preterm labor.

 

 

 

 

Chapter 16_LO03 _Q06

The nurse identifies the following assessment findings on a client with pre-eclampsia: blood pressure 158/100; urinary output 50 mL/hour; lungs clear to auscultation; urine protein 11 on dipstick; and edema of the hands, ankles, and feet. On the next hourly assessment, which of the following new assessment findings would be an indication of worsening of the pre-eclampsia?

  1. Blood pressure 158/104
  2. Urinary output 20 mL/hour
  3. Reflexes 21
  4. Platelet count 150,000

Answer: 2

Rationale:

  1. The blood pressure has not had a significant rise.
  2. The decrease in urine output is an indication of decrease in GFR, which indicates a loss of renal perfusion. The assessment finding most abnormal and life-threatening is the urine output change.
  3. The reflexes are normal at 21.
  4. The platelet count is normal, though it is at the lower end.

Cognitive Level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Assessment

Learning Outcome 16-3 Delineate the nursing care needs of a woman experiencing premature rupture of the membranes or preterm labor.

 

 

 

Chapter 16_LO04_Q07

The community nurse is working with a client at 32 weeks gestation who has been diagnosed with pre-eclampsia. Which statement indicates that additional information is needed?

  1. I should call the doctor if I develop a headache or blurred vision.
  2. Lying on my left side as much as possible is good for the baby.
  3. My urine may become darker and smaller in amount each day.
  4. Pain in the top of my abdomen is a sign my condition is worsening.

Correct Answer: 3

Rationale:

  1. Headache and blurred vision or other visual disturbances are an indication of worsening pre-eclampsia, and should be reported to the physician.
  2. Left lateral position maximizes uterine and renal blood flow, and therefore is the optimal position for a client with pre-eclampsia.
  3. Oliguria is a complication of pre-eclampsia caused by renal involvement, and is a sign that the condition is worsening. Oliguria should be reported to the physician.
  4. Epigastric pain is an indication of liver enlargement, a symptom of worsening pre-eclampsia, and should be reported to the physician.

Cognitive level: Analysis

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Evaluation

Learning Outcome: 16-4 Describe the development and course of hypertensive disorders associated with pregnancy.

 

Chapter 16_LO05_Q08

The nurse is reviewing labs on a new admit. The clients hemoglobin is 8.0; platelets are 75,000, AST 75. Which nursing action is best?

  1. Contact the physician.
  2. Request the labs to be redrawn.
  3. Assess blood pressure.
  4. Determine the clients blood type and Rh.

Correct Answer: 1

Rationale:

  1. This client has HELLP syndrome, a life-threatening condition. Further orders are needed from the physician.
  2. Redrawing the labs is not the best action; acting on the labs that indicate HELLP is a higher priority.
  3. The labs indicate HELLP syndrome. The blood pressure is likely to be high, but notifying the physician of this life-threatening set of labs is a higher priority.
  4. Although blood type and RH would need to be known after delivery to determine if the client requires RhoGAM, this is not the highest priority.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Assessment

Learning Outcome: 16-5 Relate the cause, fetal-neonatal risks, prevention, and clinical therapy to the nursing care management of the woman at risk for Rh alloimmunization.

 

 

Chapter 16 LO5 Q09

The nurse receives the following report on a client who delivered 36 hours ago: para 1, rubella immune, A-negative, antibody screen negative, newborn B-positive, Coombs negative, discharge orders are written for both mother and newborn. What should be the priority action by the nurse?

  1. Ask if she is breast- or bottle-feeding.
  2. Administer rubella vaccine.
  3. Determine if RhoGAM has been given.
  4. Discuss the discharge education with the client.

Correct answer: 3

Rationale:

  1. This is important but is not the top priority.
  2. The client is rubella-immune, and does not need the rubella vaccine.
  3. The client is A-negative and the newborn B-positive. The client needs RhoGAM prior to discharge. Without RhoGAM, the client will make antibodies against Rh-positive blood, and future pregnancies would be in jeopardy.
  4. Discharge education is always important, but in this case is not the most important action.

Cognitive Level: Analysis

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Planning

Learning Outcome: 16-5 Relate the cause, fetal-neonatal risks, prevention, and clinical therapy to the nursing care management of the woman at risk for Rh alloimmunization.

 

Chapter 16_LO06_Q10

The client with blood type A, Rh-negative delivered yesterday. Her infant is blood type AB, Rh-positive. Which statement indicates that teaching has been effective?

  1. I need to get RhoGAM so I dont have problems with my next pregnancy.
  2. Because my baby is Rh-positive, I dont need RhoGAM.
  3. If my baby had the same blood type I do, it might cause complications.
  4. Before my next pregnancy, I will need to have a RhoGAM shot.

Correct Answer: 1

Rationale:

  1. Rh-negative mothers who give birth to Rh-positive infants should receive Rh immune globulin (RhoGAM) to prevent alloimmunization, which could cause fetal anemia and other complications during the next pregnancy.
  2. Rh-negative mothers who give birth to Rh-positive infants should receive Rh immune globulin (RhoGAM) to prevent alloimmunization.
  3. It is specifically the Rh factor that causes complications; ABO grouping does not cause alloimmunization.
  4. Rh-negative mothers who give birth to Rh-positive infants should receive Rh immune globulin (RhoGAM). The injection must be given with 72 hours after delivery to prevent alloimmunization.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Evaluation

Learning Outcome: 16-6 Explain the occurrence, cause, clinical treatment, and implications for the fetus or newborn in determining nursing care management of the woman at risk for ABO incompatibility.

 

Chapter 16_LO07_Q11

Which maternalchild client should the nurse see first?

  1. Blood type O, Rh-negative
  2. Indirect Coombs test negative
  3. Direct Coombs test positive
  4. Blood type B, Rh-positive

Correct Answer:  3

Rationale:

  1. This client is Rh-negative, but there is no indication that the alloimmunization has occurred.
  2. An indirect Coombs test looks for Rh antibodies in the maternal serum; a negative result indicates the client has not been alloimmunized.
  3. A direct Coombs test looks for Rh antibodies in the fetal blood circulation. A positive result indicates that that there is an Rh incompatibility between mother and infant, and the baby is making anti-Rh antibodies, which in turn leads to hemolysis. This infant is at risk for anemia and hyperbilirubinemia.
  4. This clients blood type creates no problems.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Assessment

Learning Outcome: 16-7 Explain the occurrence, cause, clinical treatment, and implications for the fetus or newborn in determining nursing care management of woman at risk for ABO incompatibility.

 

Chapter 16_LO08_Q12

Which situation in the high-risk antepartal unit requires immediate intervention?

  1. A third-trimester client pregnant with twins who required an appendectomy yesterday is positioned in a supine position.
  2. Oxygen is being administered at 2 L via nasal cannula to a client in her third trimester who underwent an urolithotomy today.
  3. Fetal monitoring is being performed on a client in her third trimester who is scheduled for a cholecystectomy tomorrow.
  4. The client in her third trimester returned from bowel resection surgery has a nasogastric tube attached to intermittent suction.

Correct Answer: 1

Rationale:

  1. A client undergoing surgery in the third trimester should be positioned in a left lateral position or with a hip wedge placed. Being supine will cause vena cava syndrome and hypotension, which in turn will decrease fetal oxygenation. Twin gestation, with the larger uterus and heavier uterine contents, makes vena cava syndrome more problematic.
  2. Oxygen is required during and after surgery during pregnancy to maintain adequate fetal oxygenation.
  3. Fetal monitoring prior to, during, and after surgery on pregnant clients is important to assess the fetal condition.
  4. Due to the decreased peristalsis of pregnancy, pregnant clients who undergo abdominal surgery are at risk for vomiting. An NG tube is placed to prevent vomiting.

Cognitive level: Analysis

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Planning

Learning Outcome: 16-8 Examine the effects of surgical procedures in the nursing care management of the pregnant woman requiring surgery.

 

Chapter 16_LO09_Q13

The nurse is caring for a client at 35 weeks gestation who has been critically injured in a shooting. Which statement by the paramedics bringing the woman to the hospital would cause the greatest concern?

  1. Blood pressure 110/68, pulse 90.
  2. Entrance wound present below the umbilicus.
  3. Client is positioned in a left lateral tilt.
  4. Clear fluid is leaking from the vagina.

Correct Answer: 2

Rationale:

  1. These are normal vital signs, indicating a hemodynamically stable client.
  2. Penetrating abdominal trauma has a 5980% fetal injury rate. This fetus is at great risk for injury.
  3. Positioning the client in a lateral tilt position prevents vena cava syndrome.
  4. Clear fluid from the vagina could be amniotic fluid from spontaneous rupture of the membranes. Although this is not a normal finding at 35 weeks, this fetus is near term, and would likely survive birth at this time.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Assessment

Learning Outcome: 16-9 Relate the impact of trauma due to an accident to the nursing care management of the pregnant woman and her fetus.

 

Chapter 16_LO10_Q14

The nurse is admitting a client at 28 weeks gestation to the Emergency Department following an episode of domestic abuse resulting in ecchymosis and lacerations. Which question is most critical to ask?

  1. What did you do to make your spouse so angry?
  2. How many times has this happened in the past?
  3. Do you have a safe place that you can go?
  4. Will you be pressing charges against your spouse?

Correct Answer:  3

Rationale:

  1. This statement is blaming, and must be avoided to establish a trusting therapeutic relationship with an abused client.
  2. Although domestic abuse tends to increase in frequency and violence during pregnancy, this is not the highest priority.
  3. This question is the highest priority because having a safe place to go after leaving the hospital reduces the risk of repeated attack and further injury to both mother and fetus.
  4. Legal issues are a low priority at this time. Physiologic issues such as safety in the future have more important.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Planning

Learning Outcome: 16-10 Examine the needs and care of the pregnant woman who experiences abuse.

 

Chapter 16_LO11_Q15

Which statement indicates that teaching has been effective?

  1. Because I have toxoplasmosis, my baby might be born with an abnormally long body.
  2. The rubella infection I experienced in my second trimester may lead me to become deaf.
  3. My baby may develop a serious blood infection because I have group B strep in my vagina.
  4. My 8-year-olds parvovirus infection wont affect my baby because I am four months along.

Correct Answer: 3

Rationale:

  1. Toxoplasmosis during pregnancy can cause fetal microcephaly, hydrocephalus, coma, convulsions, or retinochoroiditis.
  2. Rubella infection during pregnancy can lead to fetal deafness, congenital heart defects, and developmental delays in the fetus. Maternal deafness is not a risk for perinatal rubella.
  3. Group B streptococcus can cause neonatal septicemia or pneumonia unless IV antibiotics are given during labor.
  4. Parvovirus effects on the fetus are most severe when the maternal infection occurs prior to the 20th

Cognitive level:  Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Evaluation

Learning Outcome: 16-11 Explain the cause, fetal/neonatal risks, and clinical therapy in the nursing care management of the pregnant woman with a perinatal infection affecting the fetus.

 

Chapter 32_LO01_Q01

The home care nurse is visiting a newborn and mother couplet. Which nursing action has the highest priority?

  1. Establish rapport with the family members.
  2. Review the hospital medical records.
  3. Determine sleeping arrangements of the newborn.
  4. Examine the umbilical cord stump.

Correct Answer: 1

Rationale:

  1. It is critical to establish rapport with the family members prior to beginning any assessments. A therapeutic relationship must exist to obtain accurate information or provide education.
  2. Although this is important, record review should be done prior to arriving at the home, so that the nurse is prepared. Establishing a therapeutic relationship is a higher priority at the onset of the visit.
  3. This is less important than establishing a therapeutic relationship at the onset of the visit.
  4. This is less important than establishing a therapeutic relationship at the onset of the visit.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Planning

Learning Outcome: 32.1 Identify the main purposes and components of home visits during the postpartal period.

 

Chapter 32_LO02 _Q02

The nurse is teaching experienced postpartum nurses about home care visits. Which statements indicate that teaching was effective? Select all that apply.

  1. I should tell the family to put any guns or knives away.
  2. It is best to wear professional street clothes to visits.
  3. If I encounter a crime in progress, I should leave the area.
  4. Jewelry is a good way to demonstrate my professionalism.
  5. Ignoring my gut feelings might lead to an unsafe situation.

Correct Answers: 3, 5

Rationale:

  1. The nurse should leave immediately if guns or knives are visible.
  2. It is best to wear clothing that identifies the nurse as a health care professional, such as scrubs or a lab coat.
  3. Personal safety is paramount. If a crime is encountered, the nurse should leave immediately and call 911.
  4. Jewelry should be avoided, as it might make the nurse a target of robbery.
  5. When a situation feels instinctually unsafe, the nurse should leave immediately.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Evaluation

Learning Outcome: 32.2 Examine strategies and actions a nurse should take to ensure personal safety during a home visit.

 

Chapter 32_LO02 _Q03

Which of the following safety devices is most appropriate for the nurse making home visits?

  1. Personal handgun
  2. Cellular phone
  3. Can of mace
  4. Map of the area

Answer: 2

Rationale:

  1. Personal handguns and mace are not permissible or legal for nurses to carry on home visits.
  2. Cellular phones provide a means of contact, and are advisable for the nurse to carry.
  3. Personal handguns and mace are not permissible or legal for nurses to carry on home visits.
  4. A map of the area should be checked before leaving for a visit, and the route traced.

Cognitive Level: Application

Category of Client Need: Safe, Effective Care Environment: Safety and Infection Control

Nursing Process: Planning

Learning Outcome: 32.2 Examine strategies and actions a nurse should take to ensure personal safety during a home visit.

 

Chapter 32_LO03 _Q04

The postpartum home care client asks the nurse why the visit is taking place. Which response is best? We make home care visits to:

  1. Reinforce any teaching that you didnt quite grasp in the hospital.
  2. Verify that both you and the baby are safe and doing well.
  3. Provide a service that leads to better statistical outcomes.
  4. Thoroughly assess your baby to make sure he is growing.

Correct Answer: 2

Rationale:

  1. Although reinforcement of hospital teaching is one aspect of a home care visit, this response is not therapeutically worded.
  2. Physical safety of both mom and baby are the main goals of the postpartum home care visit.
  3. Although mandated insurance coverage came about as a result of statistical analysis of outcomes of mothers and babies, the actual physical safety of mom and baby is the main reason for postpartum home care visits.
  4. This is only half of why home care visits are performed after birth. The mother is also assessed.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Implementation

Learning Outcome: 32.3 Identify the goals and nursing approaches to fostering a caring relationship in the home.

 

Chapter 32_LO04_Q05

The home care nurse is examining a newborn. The newborn is noted to be sleeping in a basket on a pillow with a stuffed animal, a fluffy blanket covering the infant. The most important nursing action is to:

  1. Remove the stuffed animal from the basket and place it on the floor.
  2. Teach the parents the risk of SIDS from soft items in the infants bed.
  3. Make certain that the blanket is firmly tucked under the baby.
  4. Ask if the color of the blanket has cultural significance.

Correct Answer:  2

Rationale:

  1. Both the fluffy blanket and the stuffed animal increase the risk of SIDS. Both should be removed after the parents are taught that these items are safety hazards.
  2. This is the highest priority.
  3. A fluffy blanket should not be used. The parents need education on fluffy items being a health hazard.
  4. Cultural significance is important, but physical safety of the newborn is a higher priority.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Implementation

Learning Outcome: 32.4 Describe the assessment and care of the newborn during postpartal home care.

 

Chapter 32_LO04_Q06

A postpartum client calls the telephone triage nurse and reports that her 2-month-old infant has a fever. She asks the nurse what to give the baby. The nurse suggests:

  1. Tylenol.
  2. Aspirin.
  3. Advil.
  4. Motrin.

Answer: 1

Rationale:

  1. Tylenol is the medication recommended by pediatricians for its antipyretic action, and also because it has a minimum of side effects in the proper form and dose.
  2. Aspirin, while also an antipyretic, has many other actions and side effects, and would not be recommended.
  3. Advil and Motrin are similar non-steroidal anti-inflammatory drugs (NSAIDs), and are not recommended for infants.
  4. Advil and Motrin are similar non-steroidal anti-inflammatory drugs (NSAIDs), and are not recommended for infants.

Cognitive Level: Application

Category of Client Need: Physiological Integrity: Pharmacological and Parental Therapies

Nursing Process: Implementation

Learning Outcome: 32.4 Describe the assessment and care of the newborn during postpartal home care.

 

Chapter 32_LO05_Q07

The nurse is performing a postpartum home care visit. Which teaching has the highest priority?

  1. Teach or review how to bathe the baby.
  2. Teaching how to thoroughly child-proof the house
  3. How many wet diapers the baby should have daily
  4. Prevention of deformational plagiocephaly

Correct Answer: 3

Rationale:

  1. Although knowing how to bathe a newborn is important, adequate hydration is a higher priority.
  2. Child-proofing the home is not necessary until the baby begins to crawl. This is a low priority at this time.
  3. Wet diapers are an indication of hydration of the newborn. This is the highest priority.
  4. Preventing flat spots on the back or side of the head is primarily a cosmetic issue. Hydration is a higher priority.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Planning

Learning Outcome: 32.5 Identify the goals for reinforcement of parent teaching in the home, and of appropriate interventions.

 

Chapter 32_LO05_Q08

To prevent sudden infant death syndrome (SIDS), the nurse encourages the parents of a term infant to place the infant in which position when the infant is sleeping?

  1. On the parents waterbed
  2. Swaddled in the infant swing
  3. On his back
  4. On his stomach

Answer: 3

Rationale:

  1. On the parents waterbed, on his stomach, or swaddled in the infant swing can increase the risks of SIDS.
  2. On the parents waterbed, on his stomach, or swaddled in the infant swing can increase the risks of SIDS.
  3. Research has shown that sleeping on the back decreases the risk of SIDS.
  4. On the parents waterbed, on his stomach, or swaddled in the infant swing can increase the risks of SIDS.

Cognitive Level: Application

Category of Client Need: Health Promotion and Maintenance: Prevention and/or Early Detection of Disease

Nursing Process: Implementation

Learning Outcome: 32.5 Identify the goals for reinforcement of parent teaching in the home, and of appropriate interventions.

 

Chapter 32_LO06_Q09

The postpartum home care nurse is assessing the mother, and finds her temperature to be 101.6F. What is the most important nursing action?

  1. Ask the client how often and how well the baby is nursing.
  2. Determine the frequency of the mothers voiding and stooling.
  3. Verify how many hours of sleep she is getting per day.
  4. Assess the odor and color of the lochia and perineum.

Correct Answer:  4

Rationale:

  1. A fever might indicate mastitis. Palpation of the breasts for warm or hardened areas is much better than asking about feedings, because mothers of good feeders can develop mastitis.
  2. If she is voiding frequently, she might have a UTI, but the frequency of bowel movements is not related to a UTI.
  3. Although it is common for new mothers to be fatigued, fatigue does not cause a fever.
  4. If the lochia is malodorous, or the perineum is reddened or malodorous, an infection is present that could be causing the fever.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Implementation

Learning Outcome: 32.6 Describe the nursing care and teaching needs of the postpartal mother and family in the first home visit based on the assessment findings and possible causes of alterations.

 

Chapter 32_LO07_Q10

The home care nurse is seeing a client at six weeks postpartum. Which statement made by the client requires immediate intervention?

  1. The baby sleeps seven hours each night now.
  2. My flow is red, and I need to wear a pad.
  3. My breasts no longer leak between feedings.
  4. I started back on the pill two weeks ago.

Correct Answer: 2

Rationale:

  1. This is an expected finding, and does not require intervention.
  2. By six weeks postpartum, lochia should be minimal in amount, requiring only a pantiliner, and should be brown or pinkish in color. Red, heavy flow is not an expected finding, and requires intervention.
  3. This is an expected finding, and does not require intervention.
  4. This is an appropriate time frame for restarting birth control pills, and does not require intervention.

Cognitive level: Analysis

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Assessment

Learning Outcome: 32.7 Relate the anticipated progress at 6 weeks of the mother and family to the assessment, identification of possible alterations, and care of the mother and

family in the home visit.

 

 

Chapter 32_LO07_Q11

The new mother hesitantly asks the nurse at the six-week postpartum visit about resumption of sexual activity. To promote comfort, the nurse suggests:

  1. The female superior position.
  2. Using Vaseline for lubrication.
  3. The male superior position.
  4. Douching before and after, to avoid infection.

Answer: 1

Rationale:

  1. The female superior position puts the least amount of pressure against the healing perineum, and creates more control of movement for the woman.
  2. Using Vaseline for lubrication is not recommended, as it is not water-soluble. K-Y Jelly is the recommended lubricant.
  3. The male superior position creates more pressure on the perineum.
  4. Douching before and after to avoid infection is never recommended.

Cognitive Level: Application

Category of Client Need: Health Promotion and Maintenance: Prevention and/or Early Detection of Disease

Nursing Process: Implementation

Learning Outcome: 32.7 Relate the anticipated progress at 6 weeks of the mother and family to the assessment, identification of possible alterations, and care of the mother and

family in the home visit.

 

Chapter 32_LO08_Q12

The postpartum nurse is performing a home care visit to a first-time mother on her third day after delivery.  She reports that her nipples are becoming sore. What statement indicates that further teaching is needed?

  1. I should try to keep the baby awake, and not let him stay latched onto the breast when he is asleep.
  2. Watching how much areola is visible will help me see if he has a good mouthful of breast or not.
  3. My nipples will heal if I switch to bottle-feeding for about three days while I pump my breasts.
  4. Rotating breastfeeding positions will allow the sore areas of my nipples to have less friction.

Correct Answer: 3

Rationale:

  1. This strategy will help prevent or heal nipple soreness.
  2. This strategy will determine whether the baby is slipping down so that he is latched on just to the nipple instead of the areola. Babies need to be latched fully onto the areola to heal nipple soreness.
  3. Switching to formula-feeding and breast-pumping is a last resort, and will decrease milk supply. Watching the latch is more important.
  4. This statement is true.

Cognitive level: Knowledge

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Evaluation

Learning Outcome: 32.8 Identify the common concerns of breastfeeding mothers following discharge, and corresponding remedies.

 

 

Chapter 32_LO09_Q13

The postpartum home care nurse has four visits to make to breastfeeding mothers. Which client is experiencing an expected outcome?

  1. Breasts are engorged; placing fresh cabbage leaves inside her bra
  2. Sore and cracked nipples; using baby oil to facilitate healing
  3. Frequent breast leakage; changing breast pads once per day
  4. Concerns about milk supply; supplementing with formula

Correct Answer: 1

Rationale:

  1. Fresh green cabbage leaves help reduce engorgement.
  2. Baby oil and other petroleum-based products should be avoided during breastfeeding, as they prolong nipple soreness, and must be washed off prior to feeding, which also increases nipple trauma.
  3. Breast pads should be changed every few hours, as breast milk is warm and rich in nutrients that bacteria find ideal for growth, which could lead to infection.
  4. Breast milk supply is regulated by demand. If a baby receives formula supplements after nursing, he will not nurse as often as he would have had he only received breast milk. This leads to decreased milk production. To increase milk production, mothers should be told to increase their fluid intake and nurse the infant more frequently.

Cognitive level: Application

Category of Client Need: Health Promotion and Main

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