NCLEX questions-Maternity (with rationales) – Flashcards
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A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She is now complaining of nausea and bloating, and states that because she had nothing to eat, she is too weak to breastfeed her infant. Which nursing diagnosis has the highest priority? A. Altered nutrition, less than body requirements for lactation B. Alteration in comfort related to nausea and abdominal distention C. Impaired bowel motility related to pain medication and immobility D.NFatigue related to cesarean delivery and physical care demands of infant
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C. Rationale: Impaired bowel motility caused by surgical anesthesia, pain medication, and immobility (C) is the priority nursing diagnosis and addresses the potential problem of a paralytic ileus. (A and B) are both caused by impaired bowel motility. (D) is not as important as impaired motility.
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The nurse is teaching care of the newborn to a childbirth preparation class and describes the need for administering antibiotic ointment into the eyes of the newborn. An expectant father asks, "What type of disease causes infections in babies that can be prevented by using this ointment?" Which response by the nurse is accurate? A.NHerpes B. Trichomonas C. Gonorrhea D. Syphilis
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C. Rationale: Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours after birth to prevent ophthalmia neonatorum, an infection caused by gonorrhea (C), and inclusion conjunctivitis, an infection caused by Chlamydia. The infant may be exposed to these bacteria when passing through the birth canal. Ophthalmic ointment is not effective against (A, B, or D).
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A new mother is having trouble breastfeeding her newborn. The child is making frantic rooting motions and will not grasp the nipple. Which intervention should the nurse implement? A. Encourage frequent use of a pacifier so that the infant becomes accustomed to sucking. B. Hold the infant's head firmly against the breast until he latches onto the nipple. C. Encourage the mother to stop feeding for a few minutes and comfort the infant. D. Provide formula for the infant until he becomes calm, and then offer the breast again.
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C. Rationale: The infant is becoming frustrated and so is the mother; both need a time out. The mother should be encouraged to comfort the infant and to relax herself (C). After such a time out, breastfeeding is often more successful. (A and D) would cause nipple confusion. (B) would only cause the infant to be more resistant, resulting in the mother and infant to become more frustrated.
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The nurse is counseling a couple who has sought information about conceiving. The couple asks the nurse to explain when ovulation usually occurs. Which statement by the nurse is correct? A. Two weeks before menstruation B. Immediately after menstruation C. Immediately before menstruation D. Three weeks before menstruation
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A. Rationale: Ovulation occurs 14 days before the first day of the menstrual period (A). 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. (B, C, and D) are incorrect.
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The nurse instructs a laboring client to use accelerated blow breathing. The client begins to complain of tingling fingers and dizziness. Which action should the nurse take? A. Administer oxygen by face mask. B. Notify the health care provider of the client's symptoms. C. Have the client breathe into her cupped hands. D. Check the client's blood pressure and fetal heart rate.
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C. Rationale: Tingling fingers and dizziness are signs of hyperventilation (blowing off too much carbon dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be facilitated by breathing into a paper bag or cupped hands (C). (A) is inappropriate because the carbon dioxide level is low, not the oxygen level. (B and D) are not specific for this situation.
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When assessing a client at 12 weeks of gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes? A. At 16 weeks of gestation B. At 20 weeks of gestation C. At 24 weeks of gestation D. At 30 weeks of gestation
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D. Rationale: Learning is facilitated by an interested pupil. The couple is most interested in childbirth toward the end of the pregnancy, when they are beginning to anticipate the onset of labor and the birth of their child. (D) is closest to the time when parents would be ready for such classes. (A, B, and C) are not the best times during a pregnancy for the couple to attend childbirth education classes. At these times they will have other teaching needs. Early pregnancy classes often include topics such as nutrition, physiologic changes, coping with normal discomforts of pregnancy, fetal development, maternal and fetal risk factors, and evolving roles of the mother and her significant others.
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One hour following a normal vaginal delivery, a newborn infant boy's axillary temperature is 96° F, his lower lip is shaking and, when the nurse assesses for a Moro reflex, the boy's hands shake. Which intervention should the nurse implement first? A. Stimulate the infant to cry. B. Wrap the infant in warm blankets. C. Feed the infant formula. D. Obtain a serum glucose level.
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D. Rationale: This infant is demonstrating signs of hypoglycemia, possibly secondary to a low body temperature. The nurse should first determine the serum glucose level (D). (A) is an intervention for a lethargic infant. (B) should be done based on the temperature, but first the glucose level should be obtained. (C) helps raise the blood sugar, but first the nurse should determine the glucose level.
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Which statement made by the client indicates that the mother understands the limitations of breastfeeding her newborn? A. "Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period." B. "Breastfeeding my baby immediately after drinking alcohol is safer than waiting for the alcohol to clear my breast milk. " C. "I can start smoking cigarettes while breastfeeding because it will not affect my breast milk. " D. "When I take a warm shower after I breastfeed, it relieves the pain from being engorged between breastfeedings. "
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A. Rationale: Continuous breastfeeding on a 3- to 4-hour schedule during the day will cause a release of prolactin, which will suppress ovulation and menses, but is not completely effective as a birth control method (A). (B) is incorrect because alcohol can immediately enter the breast milk. Nicotine is transferred to the infant in breast milk (C). Taking a warm shower will stimulate the production of milk, which will be more painful after breastfeedings (D).
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A client at 30 weeks of gestation is on bed rest at home because of increased blood pressure. The home health nurse has taught her how to take her own blood pressure and gave her parameters to judge a significant increase in blood pressure. When the client calls the clinic complaining of indigestion, which instruction should the nurse provide? A. Lie on your left side and call 911 for emergency assistance. B. Take an antacid and call back if the pain has not subsided. C. Take your blood pressure now and if it is seriously elevated, go to the hospital. D. See your health care provider to obtain a prescription for a histamine blocking agent.
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C.Rationale: Checking the blood pressure for an elevation (C) is the best instruction to give at this time. A blood pressure exceeding 140/90 mm Hg is indicative of preeclampsia. Epigastric pain can be a sign of an impending seizure (eclampsia), a life-threatening complication of gestational hypertension. Additional data are needed to confirm an emergency situation as described in (A). (B and D) ignore the threat to client safety posed by a significant increase in blood pressure.
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The nurse observes that an antepartum client who is on bed rest for preterm labor is eating ice rather than the food on her breakfast tray. The client states that she has a craving for ice and then feels too full to eat anything else. Which is the best response by the nurse? A. Remove all ice from the client's room. B. Ask the client what foods she might consider eating. C. Remind the client that what she eats affects her baby. D. Notify the health care provider.
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D. Rationale: The health care provider should be notified (D) when a client practices pica (craving for and consumption of nonfood substances). The practice of pica may displace more nutritious foods from the diet, and the client should be evaluated for anemia. (A) is overreacting and may be perceived as punishment by the patient. (B) allows the dietary department to customize the client's tray but fails to address physiologic problems associated with not consuming nutritious foods in pregnancy. (C) is judgmental and blocks further communication.
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Which finding(s) is (are) of most concern to the nurse when caring for a woman in the first trimester of pregnancy? (Select all that apply.) A. Cramping with bright red spotting B. Extreme tenderness of the breast C. Lack of tenderness of the breast D. Increased amounts of discharge E. Increased right-side flank pain
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A,C,E Rationale: (A and C) are signs of a possible miscarriage. Cramping with bright red bleeding is a sign that the client's menstrual cycle is about to begin. A decrease of tenderness in the breast is a sign that hormone levels have declined and that a miscarriage is imminent. (E) could be a sign of an ectopic pregnancy, which could be fatal if not discovered in time before rupture. (B and D) are normal signs during the first trimester of a pregnancy.
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Prior to discharge, what instructions should the nurse give to parents regarding the newborn's umbilical cord care at home? A. Wash the cord frequently with mild soap and water. B. Cover the cord with a sterile dressing. C. Allow the cord to air-dry as much as possible. D. Apply baby lotion after the baby's daily bath.
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C. Rationale: Recent studies have indicated that air drying or plain water application may be equal to or more effective than alcohol in the cord healing process (C). (A, B, and D) are incorrect because they promote moisture and increase the potential for infection.
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The nurse is evaluating a full-term multigravida who was induced 3 hours ago. The nurse determines that the client is dilated 7 cm and is 100% effaced at 0 station, with intact membranes. The monitor indicates that the FHR decelerates at the onset of several contractions and returns to baseline before each contraction ends. Which action should the nurse take? A. Reapply the external transducer. B. Insert intrauterine pressure catheter. C. Discontinue the oxytocin infusion. D. Continue to monitor labor progress.
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D. Rationale: The fetal heart rate indicates early decelerations, which are not an ominous sign, so the nurse should continue to monitor the labor progress (D) and document the findings in the client's record. There is no reason to reapply the external transducer (A) if the FHR tracings are being captured. (B and C) are not indicated at this time.
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The nurse is counseling a client who wants to become pregnant. She tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. When will the client's next fertile period occur? A. January 14 to 15 B. January 22 to 23 C. January 29 to 30 D.February 6 to 7
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C. Rationale: This client can expect her next period to begin 36 days from the first day of her last menstrual period. Her next period would begin on February 12. Ovulation occurs 14 days before the first day of the menstrual period. The client can expect ovulation to occur January 29 to 30 (C). (A, B, and D) are incorrect.
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A client who delivered a healthy infant 5 days ago calls the clinic nurse and reports that her lochia is getting lighter in color and asks when the flow will stop. How should the nurse respond? A. 2 weeks B. 10 days C. When the placental site has healed D.After the first time ovulation occurs
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C. Rationale: The placental site in the uterus usually heals (C) in 3 to 6 weeks, and the lochial flow should cease at that time. Between 2 and 6 weeks after childbirth, lochia alba occurs in most women (A). The client is describing lochia serosa, a normal change in the lochial flow (B) between days 3 and 4 after childbirth, which lasts to about day 10. (D) does not give the client the best information because ovulation varies in the postpartum period and is influenced by lactation and hormonal responses as the client's usual menstrual cycle resumes.
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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.
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B. Rationale: Attachment and bonding theory indicates that most mothers will demonstrate behaviors described in (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, C, and D).
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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
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C. Rationale: Offering to remain with the client and her partner (C) offers support without providing false reassurance. The length of labor is not always predictable, but (A and B) do not offer the client the support that is needed at this time. (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.
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In developing a teaching plan for expectant parents, the nurse decides to include information about when the parents can expect the infant's fontanels to close. Which statement is accurate regarding the timing of closure of an infant's fontanels that should be included in this teaching plan? A. The anterior fontanel closes at 2 to 4 months and the posterior fontanel by the end of the first week. B. The anterior fontanel closes at 5 to 7 months and the posterior fontanel by the end of the second week. C. The anterior fontanel closes at 8 to 11 months and the posterior fontanel by the end of the first month. D. The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the end of the second month.
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D. Rationale: In the normal infant, the anterior fontanel closes at 12 to 18 months of age and the posterior fontanel closes by the end of the second month (D). These growth and development milestones are frequently included in questions on the licensure examination. (A, B, and C) are incorrect.
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Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 mm Hg to 90/60 mm Hg. Which action should the nurse take immediately? A. Notify the health care provider or anesthesiologist. B. Continue to assess the blood pressure every 5 minutes. C. Place the client in a lateral position. D. Turn off the continuous epidural.
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C. Rationale: The nurse should immediately turn the client to a lateral position (C) or place a pillow or wedge under one hip to deflect the uterus. Other immediate interventions include increasing the rate of the main line IV infusion and administering oxygen by face mask. If the blood pressure remains low after these interventions or decreases further, the anesthesiologist or health care provider should be notified immediately (A). To continue to monitor blood pressure without taking further action (B) could constitute malpractice. (D) may also be warranted, but such action is based on hospital protocol.
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A mother who is HIV-positive delivers a full-term newborn and asks the nurse if her baby will become HIV-infected. Which explanation should the nurse provide? A. Most infants of HIV-positive women will continue to test positive for HIV antibodies. B. Infants who have HIV-positive mothers carry the virus and will eventually develop the disease. C. Medication taken during pregnancy to reduce the mother's viral load ensures that the infant is HIV-negative. D. HIV infection is determined at 18 months of age, when maternal HIV antibodies are no longer present.
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D. Rationale: All newborns of HIV-positive mothers receive passive HIV antibodies from the mother, so the evaluation of an infant for the HIV virus is determined at 18 months of age, when all the maternal antibodies are no longer in the infant's blood (D). Passive HIV antibodies disappear in the infant within 18 months of age (A). (B) is inaccurate. Although administration of HIV medication during pregnancy (C) can significantly reduce the risk of vertical transmission, treatment does not ensure that the virus will not become manifest in the infant.
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When preparing a class on newborn care for expectant parents, which is correct for the nurse to teach concerning the newborn infant born at term gestation? A. Milia are red marks made by forceps and will disappear within 7 to 10 days. B. Meconium is the first stool and is usually yellow gold in color. C. Vernix is a white cheesy substance, predominantly located in the skin folds. D. Pseudostrabismus found in newborns is treated by minor surgery.
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C. Rationale: Vernix, found in the folds of the skin, is a characteristic of term infants (C). Milia (A) are not red marks made by forceps but are white pinpoint spots usually found over the nose and chin that represent blockage of the sebaceous glands. Meconium is the first stool (B), but it is tarry black, not yellow. Pseudostrabismus (crossed eyes) is normal at birth (D) through the third or fourth month and does not require surgery.
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A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery. In developing a plan of care, the nurse should give the highest priority to which finding? A. Cyanosis of the hands and feet B. Skin color that is slightly jaundiced C. Tiny white papules on the nose or chin D. Red patches on the cheeks and trunk
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B. Rationale: Jaundice, a yellow skin coloration, is caused by elevated levels of bilirubin, which should be further evaluated in a newborn less than 24 hours old (B). Acrocyanosis (blue color of the hands and feet) is a common finding in newborns; it occurs because the capillary system is immature (A). Milia (C) are small white papules present on the nose and chin that are caused by sebaceous gland blockage, which disappear in a few weeks. Small red patches on the cheeks and trunk (D) are called erythema toxicum neonatorum, a common finding in newborns.
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A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. She sure has a funny-looking head." Which response by the nurse is best? A. "This is not an unusually shaped head, especially for a first baby." B. "It may look odd, but newborn babies are often born with heads like that." C. "That is normal. The head will return to a round shape within 7 to 10 days." D. "Your pelvis was too small, so the head had to adjust to the birth canal."
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C. Rationale: (C) reassures the mother that this is normal in the newborn and provides correct information regarding the return to a normal shape. Although (A) is correct, it implies that the client should not worry. Any implied or spoken "don't worry" is usually the wrong answer. (B) is condescending and dismissing; the mother is seeking reassurance and information. (D) is a negative statement and implies that molding is the mother's fault.
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A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. Which instruction should the nurse provide to this client? A. Breastfeed the infant, ensuring that both breasts are completely emptied. B. Feed expressed breast milk to avoid the pain of the infant latching onto the infected breast. C.Breastfeed on the unaffected breast only until the mastitis subsides. D. Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the infant.
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A. Rationale: Mastitis, caused by plugged milk ducts, is related to breast engorgement, and breastfeeding during mastitis facilitates the complete emptying of engorged breasts (A), eliminating the pressure on the inflamed breast tissue. (B) is less painful but does not facilitate complete emptying of the breast tissue. (C) will not relieve the engorgement on the affected side. (D) will not decrease antibiotic effects on the infant.
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The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most important to include in the teaching plan? A. Avoid alcohol because it is excreted in breast milk. B. Eat a high-roughage diet to help prevent constipation. C. Increase caloric intake by approximately 500 cal/day. D. Increase fluid intake to at least 3 quarts each day.
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A. Rationale: Alcohol should be avoided while breastfeeding because it is excreted in breast milk (A) and may cause a variety of problems, including slower growth and cognitive impairment for the infant. (B, C, and D) should also be included in diet teaching for a breastfeeding mother; however, because these do not involve safety of the infant, they do not have the same degree of importance as (A).
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The client comes to the hospital assuming she is in labor. Which assessment finding(s) by the nurse would indicate that the client is in true labor? (Select all that apply.) A. Pain in the lower back that radiates to abdomen B. Contractions decreased in frequency with ambulation C. Progressive cervical dilation and effacement D. Discomfort localized in the abdomen E. Regular and rhythmic painful contractions
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A,C,E Rationale: These are all signs of true labor (A, C, and E). The others are signs of false labor (B and D).
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A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective in preventing nipple soreness? A. Wear a cotton bra with nonbinding support. B. Increase nursing time gradually over several days. C. Ensure that the baby is positioned correctly for latching on. D. Manually express a small amount of milk before nursing.
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C. Rationale: The most common cause of nipple soreness is incorrect positioning (C) of the infant on the breast for latching on. The baby's body is in alignment with ears, shoulders, and hips in a straight line, with the nose, cheeks, and chin touching the breast. (A) helps prevent chafing, and nonbinding support aids in prevention of discomfort from the stretching of Cooper's ligament. (B) is important but is not necessary for all women. (D) helps soften an engorged breast and encourages correct infant latching on but is not the best answer.
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A mother expresses fear about changing the infant's diaper after circumcision. What information should the nurse include in the teaching plan? A. Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours. B. Wash off the yellow exudate on the glans once every day to prevent infection. C. Place petroleum ointment around the glans with each diaper change and cleansing. D. Apply pressure by squeezing the penis with the fingers for 5 minutes if bleeding occurs.
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C. Rationale: With each diaper change, the glans penis should be washed with warm water to remove any urine or feces and petroleum ointment (C) should be applied to prevent the diaper from sticking to the healing surface. Prepackaged wipes (A) often contain other products that may irritate the site. The yellow exudate, which covers the glans penis as the area heals and epithelializes, is not an infective process and should not be removed (B). If bleeding occurs at home, the client should be instructed to apply gentle pressure (D) to the site of the bleeding with sterile gauze squares and call the health care provider.
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An expectant father tells the nurse he fears that his wife "is losing her mind." He states that she is constantly rubbing her abdomen and talking to the baby and that she actually reprimands the baby when it moves too much. Which recommendation should the nurse make to this expectant father? A. Suggest that his wife seek professional counseling to deal with her symptoms. B. Explain that his wife is exhibiting ambivalence about the pregnancy. C. Ask him to report similar abnormal behaviors at the next prenatal visit. D. Reassure him that normal maternal-fetal bonding is occurring.
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D. Rationale: These behaviors are positive signs of maternal-fetal bonding (D) and do not reflect ambivalence (B). No intervention is needed. Quickening, the first perception of fetal movement, occurs at 17 to 20 weeks of gestation and begins a new phase of prenatal bonding during the second trimester. (A and C) are not necessary because the behaviors displayed are normal.
