correct answers
A 3-day-breastfeeding client who is not immune to rubella is to receive the rubella vaccine at
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discharge. Which of the following must the nurse include in her discharge teaching regarding
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the vaccine? e
1. The woman should not become pregnant for at least 4 weeks.
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2. The woman should pump and dump her breast milk for 1 week.
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3. Surgical masks must be worn by the mother when she holds the baby.
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4. Antibodies transported through the breast milk will protect the baby. - correct answers1
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1. This statement is correct.
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2. The rubella vaccine is a live attenuated vaccine. Severe birth defects can develop if the
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woman becomes pregnant within 4 weeks of receiving the injection.
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3. This is unnecessary. There is no risk to the baby whether the mother is bottle feeding or
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breastfeeding.This statement is incorrect. There is no risk to the baby. e e e e e e e e e e
4. This statement is incorrect.
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A 3-day-postpartum client questions why she is to receive the rubella vaccine before leaving
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the hospital. Which of the following rationales should guide the nurse's response?
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1.The client's obstetric status is optimal for receiving the vaccine.
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2. The client's immune system is highly responsive during the postpartum period.
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3. The client's baby will be high risk for acquiring rubella if the woman does not
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receive the vaccine. e e
4. The client's insurance company will pay for the shot if it is given during the
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immediate postpartum period. - correct answers1 e e e e e
1 This statement is correct. Because the vaccine is teratogenic, the best time to administer it is
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when the client is not pregnant.
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,This statement is incorrect. The immune systems of women during their pregnancies and
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immediately postpartum are slightly depressed. e e e e
This statement is incorrect. The baby will be susceptible to rubella whether or not the woman
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receives the vaccine.In general, insurance companies will pay for vaccinations whenever e e e e e e e e e e e
they are needed. e e
A patient, G2 P1102, who delivered her baby 8 hours ago, now has a temperature of 100.2°F.
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Which of the following is the appropriate nursing intervention at this time?
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1. Notify the doctor to get an order for acetaminophen.
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2. Request an infectious disease consult from the doctor.
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3. Provide the woman with cool compresses.
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4. Encourage intake of water and other fluids. - correct answers4
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1. A temperature of 100.2°F is not a febrile temperature. It is unlikely that this client needs
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acetaminophen.
2. A temperature of 100.2°F is not a febrile temperature. It is unlikely that this client is infected.
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3. A temperature of 100.2°F is not a febrile temperature. It is unlikely that this client needs cool
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compresses.
4. It is likely that this client is dehydrated. She should be advised to drink fluids.
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To prevent infection, the nurse teaches the postpartum client to perform which of the following
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tasks?
1. Apply antibiotic ointment to the perineum daily.
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2. Change the peripad at each voiding.
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3. Void at least every two hours.
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4. Spray the perineum with povidone-iodine after toileting. - correct answers2
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1. It is unnecessary to apply antibiotic ointment to the perineum after delivery.
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2. Clients should be advised to change their pads at each voiding.
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3. The clients should void about every 2 hours, but this action is not an infection control
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measure.
4. It is unnecessary to spray the perineum with a povidone-iodine solution. Plain water,
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however, should be sprayed on the perineum. e e e e e e
A 3-day-postpartum breastfeeding woman is being assessed. Her breasts are firm and warm
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to the touch. When asked when she last fed the baby her reply is, "I fed the baby last evening. I
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let the nurses feed him in the nursery last night. I needed to rest." Which of the following actions
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should the nurse take at this time?
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1. Encourage the woman exclusively to breastfeed her baby.
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2. Have the woman massage her breasts hourly.
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3. Obtain an order to culture her expressed breast milk.
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4. Take the temperature and pulse rate of the woman. - correct answers1
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Clients should be strongly encouraged exclusively to breastfeed their babies to prevent
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engorgement.Massaging of the breast will stimulate more milk production. That is not the best e e e e e e e e e e e e e
action to take.
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It is unnecessary to culture the breast. This client is engorged; she does not have an
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infection.It is unnecessary to assess this client's temperature and pulse rate. This client is e e e e e e e e e e e e e e
engorged; she is not infected. e e e e
,A breastfeeding woman has been counseled on how to prevent engorgement. Which of the
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following actions by the mother shows that the teaching was effective? e e e e e e e e e e
1. She pumps her breasts after each feeding.
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2. She feeds her baby every 2 to 3 hours.
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3. She feeds her baby 10 minutes on each side.
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4. She supplements each feeding with formula. - correct answers2
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Clients are not recommended to pump their breasts after feedings unless there is a specific
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reason to do so.This statement is true. The best way to prevent engorgement is to feed the
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baby every 2 to 3 hours. e e e e e
Clients should not restrict babies' feeding times. Babies feed at different rates. Babies
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themselves, therefore, should regulate the amount of time they need to complete their feeds. e e e e e e e e e e e e e
Clients are not recommended to supplement with formula unless there is a specific reason to
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do so. e
A 2-day-postpartum breastfeeding woman states, "I am sick of being fat. When can I go on a
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diet?" Which of the following responses is appropriate?
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1. "It is fine for you to start dieting right now as long as you drink plenty of milk."
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2. "Your breast milk will be low in vitamins if you start to diet while breastfeeding."
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3. "You must eat at least 3,000 calories per day in order to produce enough milk for
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your baby." e
4. "Many mothers lose weight when they breastfeed because the baby consumes
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about 600 calories a day." - correct answers4 e e e e e e e
It is not recommended that breastfeeding mothers go on weight-reduction diets. In addition, it
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is not necessary for mothers to drink milk to make breast milk.
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When a breastfeeding woman has a poor diet, the quality of her breast milk changes very little.
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In fact, if a mother consumes a poor diet, it is her own body that will suffer. Mothers do not need
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to eat 3,000 calories a day while breastfeeding.
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Many mothers who consume approximately the same number of calories while
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breastfeeding as they did when they were pregnant do lose weight while breastfeeding. e e e e e e e e e e e e
A G2 P2002 who is postpartum 6 hours from a spontaneous vaginal delivery is assessed. The
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nurse notes that the fundus is firm at the umbilicus, there is heavy lochia rubra, and perineal
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sutures are intact. Which of the following actions should the nurse take at this time?
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1. Do nothing. This is a normal finding.
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2. Massage the woman's fundus.
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3. Take the woman to the bathroom to void.
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4. Notify the woman's primary healthcare provider. - correct answers4
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A client informs the nurse that she intends to bottle feed her baby. Which of the following
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actions should the nurse encourage the client to perform? Select all that apply.
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1. Increase her fluid intake for a few days.
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2. Massage her breasts every 4 hours.
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3. Apply heat packs to her axillae.
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4. Wear a supportive bra 24 hours a day.
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5. Stand with her back toward the shower water. - correct answers4 and 5 are correct.
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, It is unnecessary for a bottle-feeding mother to increase her fluid intake.
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It is inadvisable for a bottle-feeding mother to massage her breasts.
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It is inadvisable for a bottle-feeding mother to apply heat to her breasts.
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The mother should be advised to wear a supportive bra 24 hours a day for a week or so.
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The mother should be advised to stand with her back toward the warm shower water.
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The nurse in the obstetric clinic received a telephone call from a bottle-feeding mother of a 3-
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day-old. The client states that her breasts are firm, red, and warm to the touch. Which of the
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following is the best action for the nurse to advise the client to perform? e e e e e e e e e e e e e
1. Intermittently apply ice packs to her axillae and breasts.
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2. Apply lanolin to her breasts and nipples every 3 hours.
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3. Express milk from the breasts every 3 hours.
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4. Ask the primary healthcare provider to order a milk suppressant. - correct answers1
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A multigravid, postpartum woman reports severe abdominal cramping whenever she nurses
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her baby. Which of the following responses by the nurse is appropriate?
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1. Suggest that the woman bottle feed for a few days.
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2. Instruct the patient on how to massage her fundus.
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3. Instruct the patient to feed using an alternate position.
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4. Discuss the action of breastfeeding hormones. - correct answers4
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The nurse is caring for a breastfeeding mother who asks advice on foods that will provide both
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vitamin A and iron. Which of the following should the nurse recommend?
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1. 1⁄2 cup raw celery dipped in 1 ounce cream cheese.
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2. 8 ounces yogurt mixed with 1 medium banana.
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3. 12 ounces strawberry milk shake.
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4. 11⁄2 cups raw broccoli. - correct answers4
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A breastfeeding mother states that she has sore nipples. In response to the complaint, the
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nurse assists with "latch on" and recommends that the mother do which of the following?
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1. Use a nipple shield at each breastfeeding.
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2. Cleanse the nipples with soap 3 times a day.
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3. Rotate the baby's positions at each feed.
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4. Bottle feed for 2 days then resume breastfeeding. - correct answers3
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Which of the following statements is true about breastfeeding mothers as compared to bottle-
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feeding mothers? e
1. Breastfeeding mothers usually involute completely by 3 weeks postpartum.
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2. Breastfeeding mothers have decreased incidence of diabetes mellitus later in life.
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3. Breastfeeding mothers show higher levels of bone density after menopause.
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4. Breastfeeding mothers are prone to fewer bouts of infection immediately postpartum. -
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correct answers2 e
A breastfeeding woman, 11⁄2 months postdelivery, calls the nurse in the obstetrician's office
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and states, "I am very embarrassed but I need help. Last night I had an orgasm when my
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husband and I were making love. You should have seen the milk. We were both soaking wet.
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