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Questions 158

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Question 1 of 5

Which skin assessment in a newborn indicates a need for follow-up?

Correct Answer: D

Rationale: Jaundice at birth is abnormal and may indicate hemolytic disease liver dysfunction or other serious conditions requiring immediate follow-up. Miliaria rubra erythema toxicum and Mongolian spots are benign and common in newborns.

Question 2 of 5

A client with pregnancy-induced hypertension is scheduled for a C-section. Before surgery, the nurse should keep the client:

Correct Answer: C

Rationale: The left lateral position improves uteroplacental blood flow in pregnancy-induced hypertension, reducing fetal distress risk. Right-sided, supine, or knee-chest positions are less optimal.

Question 3 of 5

The postpartum nurse should include which of the following instructions to breast-feeding mothers?

Correct Answer: C

Rationale: Limiting initial feeding times will only delay nipple soreness as well as the establishment of the letdown reflex, thus encouraging engorgement from clogged ducts and ductules. Soap should be avoided because it may be excessively drying, predisposing nipples to cracking. For optimal milk production, an additional 500 kcal over maintenance levels are needed daily. Lipase, not lactose, emulsifies the fat in breast milk, making it almost totally digestible by infants.

Question 4 of 5

The client is admitted with a diagnosis of gastroenteritis. Which precaution should the nurse implement?

Correct Answer: B

Rationale: Gastroenteritis is often caused by pathogens like norovirus, requiring contact precautions to prevent fecal-oral transmission. Standard precautions are insufficient, and droplet or airborne are not indicated.

Question 5 of 5

The nurse is assisting a 4th-day postoperative cholecystectomy client in planning her meals for tomorrow's menu. Which vitamin is the most essential in promoting tissue healing?

Correct Answer: A

Rationale: Vitamin C (ascorbic acid) is essential in promoting wound healing and collagen formation. Vitamin B1 (thiamine) maintains normal gastrointestinal (GI) functioning, oxidizes carbohydrates, and is essential for normal functioning of nervous tissue. Vitamin D regulates absorption of calcium and phosphorus from the GI tract and helps prevent rickets. Vitamin A is necessary for the formation and maintenance of skin and mucous membranes. It is also essential for normal growth and development of bones and teeth.

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