100% VERIFIED ANSWERS
1. A nurse is providing discharge teaching to a client who is 3 days
postpartum and is formula feeding their newborn. Which of the
following instructions should the nurse include when discussing
engorgement?
A. Apply ice packs to the breasts for 15 minutes to relieve swelling and
discomfort
B. Wear a loose-fitting bra for 1 week to minimize pressure on the
breasts
C. Manually express small amounts of breastmilk three times per day
D. Allow warm water from a shower to run over the breasts twice a day
Correct Answer: A
Rationale: The nurse should instruct the client to apply ice packs to
their breasts in a pattern of 15 min on and 45 min off to help relieve
engorgement by reducing swelling. A snug, supportive bra is
recommended, not a loose one. Manual expression stimulates milk
production and worsens engorgement. Warm water increases blood
flow and swelling.
2. A nurse is caring for a client who is in early labor and has a fetus in
occipitoposterior presentation. The client reports pain in their lower
back with contractions. Which of the following pain management
,techniques is most likely to be effective in relieving low back pain
caused by this type of fetal presentation?
A. Counterpressure
B. Effleurage
C. Therapeutic touch
D. Breathing techniques
Correct Answer: A
Rationale: Counterpressure involves steady pressure applied to the
sacral area during contractions, which lifts the fetal head off the sacral
nerves and decreases pain. Effleurage is light abdominal massage,
therapeutic touch is energy-based, and breathing techniques help with
general pain but do not specifically target back pain from
occipitoposterior position.
3. A nurse is teaching the parents of a newborn about bathing
techniques. Which of the following instructions should the nurse
include?
A. Bathe the newborn once per day
B. Bathe the newborn after a feeding
C. Clean the newborn's face first using plain water
D. Clean the newborn's ears and nose with cotton swabs
Correct Answer: C
Rationale: The face should be washed first with plain water, then the
rest of the body with mild soap from neck to toes, saving the genitals
for last. Bathing 2–3 times per week is sufficient. Bathing after feeding
,can cause regurgitation. Cotton swabs should never be used in the ears
or nose due to injury risk.
4. A nurse is providing teaching about danger signs during pregnancy
to a client who is at 20 weeks gestation. The nurse should instruct the
client to report headaches, blurred vision, and epigastric pain because
these are indications of which of the following complications of
pregnancy?
A. Gestational diabetes
B. Preeclampsia
C. Hyperemesis gravidarum
D. Abruptio placentae
Correct Answer: B
Rationale: Headache, vision changes, epigastric or abdominal pain, and
facial/hand edema are classic manifestations of preeclampsia. These
signs indicate worsening hypertension and potential end-organ damage.
5. A nurse is assessing the fundal height for a client who is at 28 weeks
gestation. The nurse should measure the distance in centimeters
between which two anatomical landmarks?
A. The mons pubis and the xiphoid process
B. The top of the fundus and the umbilicus
C. The symphysis pubis and the top of the fundus
D. The mons pubis and the umbilicus
, Correct Answer: C
Rationale: Fundal height is measured from the upper border of the
symphysis pubis to the top of the fundus. The measurement in
centimeters should correspond to the gestational week ± 2 cm between
18 and 30 weeks.
6. A nurse is assessing a newborn who was born two days ago. Which
of the following findings should the nurse report to the provider?
A. Blackening of the stump of the umbilical cord
B. Redness of the skin at the base of the umbilical cord stump
C. Scant amount of dried blood on the skin around the umbilical cord
stump
D. Hardening of the umbilical cord
Correct Answer: B
Rationale: Redness at the base of the umbilical cord indicates infection
and requires immediate reporting. Other signs include swelling,
purulent drainage, and foul odor. Blackening, drying, and hardening are
expected as the cord separates.
7. A nurse is providing teaching about breastfeeding to a client who
gave birth 8 hours ago. Which of the following information should the
nurse include?
A. The newborn should be fed six times in 24 hours
B. The newborn should have six wet diapers per day after day 4
C. The breasts will become engorged within 24 hours of the first feeding
D. The newborn should be breastfed on a set schedule