Testbank For NSG 3500 - Exam 3 Questions
with 100% Correct Solutions
A 3-day-breastfeeding client who is not immune to rubella is to receive the
rubella vaccine at discharge. Which of the following must the nurse include
in her discharge teaching regarding the vaccine?
1. The woman should not become pregnant for at least 4 weeks.
2. The woman should pump and dump her breast milk for 1 week.
3. Surgical masks must be worn by the mother when she holds the baby.
4. Antibodies transported through the breast milk will protect the baby. -
Correct Answer 1
1. This statement is correct.
2. The rubella vaccine is a live attenuated vaccine. Severe birth defects can
develop if the woman becomes pregnant within 4 weeks of receiving the
injection.
3. This is unnecessary. There is no risk to the baby whether the mother is
bottle feeding or breastfeeding.This statement is incorrect. There is no risk
to the baby.
4. This statement is incorrect.
A 3-day-postpartum client questions why she is to receive the rubella
vaccine before leaving the hospital. Which of the following rationales
should guide the nurse's response?
1.The client's obstetric status is optimal for receiving the vaccine.
2. The client's immune system is highly responsive during the postpartum
period.
,3. The client's baby will be high risk for acquiring rubella if the woman does
not
receive the vaccine.
4. The client's insurance company will pay for the shot if it is given during
the
immediate postpartum period. - Correct Answer 1
1 This statement is correct. Because the vaccine is teratogenic, the best
time to administer it is when the client is not pregnant.
This statement is incorrect. The immune systems of women during their
pregnancies and immediately postpartum are slightly depressed.
This statement is incorrect. The baby will be susceptible to rubella whether
or not the woman receives the vaccine.In general, insurance companies
will pay for vaccinations whenever they are needed.
A patient, G2 P1102, who delivered her baby 8 hours ago, now has a
temperature of 100.2°F. Which of the following is the appropriate nursing
intervention at this time?
1. Notify the doctor to get an order for acetaminophen.
2. Request an infectious disease consult from the doctor.
3. Provide the woman with cool compresses.
4. Encourage intake of water and other fluids. - Correct Answer 4
1. A temperature of 100.2°F is not a febrile temperature. It is unlikely that
this client needs acetaminophen.
2. A temperature of 100.2°F is not a febrile temperature. It is unlikely that
this client is infected.
3. A temperature of 100.2°F is not a febrile temperature. It is unlikely that
this client needs cool compresses.
,4. It is likely that this client is dehydrated. She should be advised to drink
fluids.
To prevent infection, the nurse teaches the postpartum client to perform
which of the following tasks?
1. Apply antibiotic ointment to the perineum daily.
2. Change the peripad at each voiding.
3. Void at least every two hours.
4. Spray the perineum with povidone-iodine after toileting. - Correct Answer
2
1. It is unnecessary to apply antibiotic ointment to the perineum after
delivery.
2. Clients should be advised to change their pads at each voiding.
3. The clients should void about every 2 hours, but this action is not an
infection control measure.
4. It is unnecessary to spray the perineum with a povidone-iodine solution.
Plain water, however, should be sprayed on the perineum.
A 3-day-postpartum breastfeeding woman is being assessed. Her breasts
are firm and warm to the touch. When asked when she last fed the baby
her reply is, "I fed the baby last evening. I let the nurses feed him in the
nursery last night. I needed to rest." Which of the following actions should
the nurse take at this time?
1. Encourage the woman exclusively to breastfeed her baby.
2. Have the woman massage her breasts hourly.
3. Obtain an order to culture her expressed breast milk.
4. Take the temperature and pulse rate of the woman. - Correct Answer 1
, Clients should be strongly encouraged exclusively to breastfeed their
babies to prevent engorgement.Massaging of the breast will stimulate more
milk production. That is not the best action to take.
It is unnecessary to culture the breast. This client is engorged; she does
not have an infection.It is unnecessary to assess this client's temperature
and pulse rate. This client is engorged; she is not infected.
A breastfeeding woman has been counseled on how to prevent
engorgement. Which of the following actions by the mother shows that the
teaching was effective?
1. She pumps her breasts after each feeding.
2. She feeds her baby every 2 to 3 hours.
3. She feeds her baby 10 minutes on each side.
4. She supplements each feeding with formula. - Correct Answer 2
Clients are not recommended to pump their breasts after feedings unless
there is a specific reason to do so.This statement is true. The best way to
prevent engorgement is to feed the baby every 2 to 3 hours.
Clients should not restrict babies' feeding times. Babies feed at different
rates. Babies themselves, therefore, should regulate the amount of time
they need to complete their feeds.
Clients are not recommended to supplement with formula unless there is a
specific reason to do so.
A 2-day-postpartum breastfeeding woman states, "I am sick of being fat.
When can I go on a diet?" Which of the following responses is appropriate?
1. "It is fine for you to start dieting right now as long as you drink plenty of
milk."
with 100% Correct Solutions
A 3-day-breastfeeding client who is not immune to rubella is to receive the
rubella vaccine at discharge. Which of the following must the nurse include
in her discharge teaching regarding the vaccine?
1. The woman should not become pregnant for at least 4 weeks.
2. The woman should pump and dump her breast milk for 1 week.
3. Surgical masks must be worn by the mother when she holds the baby.
4. Antibodies transported through the breast milk will protect the baby. -
Correct Answer 1
1. This statement is correct.
2. The rubella vaccine is a live attenuated vaccine. Severe birth defects can
develop if the woman becomes pregnant within 4 weeks of receiving the
injection.
3. This is unnecessary. There is no risk to the baby whether the mother is
bottle feeding or breastfeeding.This statement is incorrect. There is no risk
to the baby.
4. This statement is incorrect.
A 3-day-postpartum client questions why she is to receive the rubella
vaccine before leaving the hospital. Which of the following rationales
should guide the nurse's response?
1.The client's obstetric status is optimal for receiving the vaccine.
2. The client's immune system is highly responsive during the postpartum
period.
,3. The client's baby will be high risk for acquiring rubella if the woman does
not
receive the vaccine.
4. The client's insurance company will pay for the shot if it is given during
the
immediate postpartum period. - Correct Answer 1
1 This statement is correct. Because the vaccine is teratogenic, the best
time to administer it is when the client is not pregnant.
This statement is incorrect. The immune systems of women during their
pregnancies and immediately postpartum are slightly depressed.
This statement is incorrect. The baby will be susceptible to rubella whether
or not the woman receives the vaccine.In general, insurance companies
will pay for vaccinations whenever they are needed.
A patient, G2 P1102, who delivered her baby 8 hours ago, now has a
temperature of 100.2°F. Which of the following is the appropriate nursing
intervention at this time?
1. Notify the doctor to get an order for acetaminophen.
2. Request an infectious disease consult from the doctor.
3. Provide the woman with cool compresses.
4. Encourage intake of water and other fluids. - Correct Answer 4
1. A temperature of 100.2°F is not a febrile temperature. It is unlikely that
this client needs acetaminophen.
2. A temperature of 100.2°F is not a febrile temperature. It is unlikely that
this client is infected.
3. A temperature of 100.2°F is not a febrile temperature. It is unlikely that
this client needs cool compresses.
,4. It is likely that this client is dehydrated. She should be advised to drink
fluids.
To prevent infection, the nurse teaches the postpartum client to perform
which of the following tasks?
1. Apply antibiotic ointment to the perineum daily.
2. Change the peripad at each voiding.
3. Void at least every two hours.
4. Spray the perineum with povidone-iodine after toileting. - Correct Answer
2
1. It is unnecessary to apply antibiotic ointment to the perineum after
delivery.
2. Clients should be advised to change their pads at each voiding.
3. The clients should void about every 2 hours, but this action is not an
infection control measure.
4. It is unnecessary to spray the perineum with a povidone-iodine solution.
Plain water, however, should be sprayed on the perineum.
A 3-day-postpartum breastfeeding woman is being assessed. Her breasts
are firm and warm to the touch. When asked when she last fed the baby
her reply is, "I fed the baby last evening. I let the nurses feed him in the
nursery last night. I needed to rest." Which of the following actions should
the nurse take at this time?
1. Encourage the woman exclusively to breastfeed her baby.
2. Have the woman massage her breasts hourly.
3. Obtain an order to culture her expressed breast milk.
4. Take the temperature and pulse rate of the woman. - Correct Answer 1
, Clients should be strongly encouraged exclusively to breastfeed their
babies to prevent engorgement.Massaging of the breast will stimulate more
milk production. That is not the best action to take.
It is unnecessary to culture the breast. This client is engorged; she does
not have an infection.It is unnecessary to assess this client's temperature
and pulse rate. This client is engorged; she is not infected.
A breastfeeding woman has been counseled on how to prevent
engorgement. Which of the following actions by the mother shows that the
teaching was effective?
1. She pumps her breasts after each feeding.
2. She feeds her baby every 2 to 3 hours.
3. She feeds her baby 10 minutes on each side.
4. She supplements each feeding with formula. - Correct Answer 2
Clients are not recommended to pump their breasts after feedings unless
there is a specific reason to do so.This statement is true. The best way to
prevent engorgement is to feed the baby every 2 to 3 hours.
Clients should not restrict babies' feeding times. Babies feed at different
rates. Babies themselves, therefore, should regulate the amount of time
they need to complete their feeds.
Clients are not recommended to supplement with formula unless there is a
specific reason to do so.
A 2-day-postpartum breastfeeding woman states, "I am sick of being fat.
When can I go on a diet?" Which of the following responses is appropriate?
1. "It is fine for you to start dieting right now as long as you drink plenty of
milk."
