The nurse is counseling a couple who has sought information about conceiving. The couple asks the nurse to explain when ovulation usually occurs. Which
... [Show More] statement by the nurse is correct?
A. Two weeks before menstruation
B. Immediately after menstruation
C. Immediately before menstruation
D. Three weeks before menstruation
(Ans- A
Rationale:
Ovulation occurs 14 days before the first day of the menstrual period. Although ovulation can occur in the middle of the cycle or 2 weeks after menstruation, this is only true for a woman who has a perfect 28-day cycle. For many women, the length of the menstrual cycle varies. Options B, C, and D are incorrect.
A client in active labor is becoming increasingly fearful because her contractions are occurring more often than she had expected. Her partner is also becoming anxious. Which of the following should be the focus of the nurse's response?
A. Telling the client and her partner that the labor process is often unpredictable
B. Informing the client that this means she will give birth sooner than expected
C. Asking the client and her partner if they would like the nurse to stay in the room
D. Affirming that the fetal heart rate is remaining within normal limits
(Ans- C
Rationale:
Offering to remain with the client and her partner offers support without providing false reassurance. The length of labor is not always predictable, but options A and B do not offer the client the support that is needed at this time. Option D may be reassuring regarding the fetal heart rate but does not provide the client the emotional support she needs at this time during the labor process.
A newborn infant, diagnosed with developmental dysplasia of the hip (DDH), is being prepared for discharge. Which nursing intervention should be included in this infant's discharge teaching plan?
A. Observe the parents applying a Pavlik harness.
B. Provide a referral for an orthopedic surgeon.
C. Schedule a physical therapy follow-up home visit.
D. Teach the parents to check for hip joint mobility.
(Ans- A
Rationale:
It is important that the hips of infants with hip dysplasia are maintained in an abducted position, which can be accomplished by using the Pavlik harness; this keeps the hips and knees flexed, the hips abducted, and the femoral head in the acetabulum. Early treatment often negates the need for surgery, and option B is not indicated until approximately 6 months of age. Option C is not indicated for hip dysplasia. It is best for the pediatrician to monitor hip joint mobility, and teaching the parents to perform this technique is likely to increase their anxiety.
A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" Which explanation is appropriate?
A. "Weigh the baby daily, and if she is gaining weight, she is getting enough to eat."
B. "Your milk is sufficient if the baby is voiding pale, straw-colored urine six to ten times a day."
C. "Offer the baby extra bottled milk after her feeding and see if she still seems hungry."
D. "If you're concerned, you might consider bottle feeding so that you can monitor intake."
(Ans- B
Rationale:
The urine will be dilute (straw-colored) and frequent (>6 to 10 times/day), if the infant is adequately hydrated. Although a weight gain of 30 g/day is indicative of adequate nutrition, most home scales do not measure this accurately, and the suggestion will likely make the mother anxious. Option C causes nipple confusion and diminishes the mother's milk production. Option D does not address the client's question.
Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time?
A. She eagerly reaches for the infant, undresses the infant, and examines the infant completely.
B. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips.
C. Her arms and hands receive the infant and she then cuddles the infant to her own body.
D. She eagerly reaches for the infant and then holds the infant close to her own body.
(Ans- B
Rationale:
Attachment and bonding theory indicates that most mothers will demonstrate behaviors described in option B during the first visit with the newborn, which may be at delivery or later. After the first visit, the mother may exhibit different touching behaviors such as eagerly reaching for the infant and cuddling the infant close to her.
A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. Which instruction should the nurse provide to this client? [Show Less]