A client who is postpartum and has thrombophlebitis requires nursing interventions. Which of the following nursing interventions should the nurse recommend?

Correct Answer: D

Rationale: The correct answer is D - Measure leg circumferences. This is important in assessing for changes in swelling, which can indicate worsening thrombophlebitis. Monitoring leg circumferences helps in early detection of complications like deep vein thrombosis. Applying cold compresses (A) can worsen vasoconstriction, massage (B) can dislodge clots, and allowing ambulation (C) can increase the risk of clot migration.

Correct Answer: B

Rationale: The correct answer is B: 48/min. The normal respiratory rate for a newborn is typically between 30-60 breaths per minute. It is important to assess a newborn's respiratory rate to ensure proper oxygenation. Option A (22/min) is too low, while options C (100/min) and D (110/min) are too high and could indicate respiratory distress or other issues that need immediate attention. Therefore, option B falls within the expected reference range and is the correct answer for a healthy newborn assessment.

Correct Answer: C

Rationale: The correct answer is C. Tilt the bottle to prevent air from entering as the baby sucks is incorrect. It is important not to tilt the bottle as it can cause the baby to swallow air, leading to gas and discomfort. A: Keeping the baby's head elevated helps prevent choking. B: Allowing the baby to burp reduces gas and discomfort. D: Soft, formed yellow stools indicate a healthy digestive system. Thus, C is the only statement that may lead to issues and requires further instruction.

Correct Answer: C

Rationale: The correct answer is C. Cleaning the penis with each diaper change is crucial for proper circumcision care to prevent infection. This statement shows understanding of the teaching as it emphasizes the importance of keeping the area clean. A: The circumcision healing within a couple of days is incorrect as it usually takes about 1-2 weeks. B: Not removing the yellow mucus can lead to infection, so this is an incorrect statement. D: Giving a tub bath within a couple of days can increase the risk of infection, so this statement is incorrect.

Correct Answer: D

Rationale: The correct answer is D: Position the newborn skin-to-skin on the client's chest. This promotes bonding through touch, warmth, and smell, stimulating the release of oxytocin in both the parent and the infant. Skin-to-skin contact enhances attachment, regulates the newborn's temperature and breathing, and supports breastfeeding initiation. A: Encouraging parents to touch and explore the newborn's features is important but not as crucial as immediate skin-to-skin contact for bonding and physiological benefits. B: Limiting noise and interruptions can create a calm environment but does not directly promote bonding like skin-to-skin contact. C: Placing the newborn at the client's breast is beneficial for breastfeeding initiation but may not provide the same level of closeness and comfort as skin-to-skin contact.

Correct Answer: D

Rationale: The correct answer is D because a baby who is postmature may have dry, cracked, and peeling skin, leading to a leathery appearance due to prolonged exposure to amniotic fluid. This occurs as the protective vernix caseosa diminishes over time. Choice A is incorrect because excess baby fat is not a typical characteristic of postmaturity. Choice B is incorrect as flat areola without breast buds is not a common feature of postmaturity. Choice C is incorrect as the ability to easily move heels to ears is a sign of flexibility and does not specifically relate to postmaturity.

Correct Answer: B

Rationale: The correct answer is B: Rooting. This reflex helps the newborn turn their head towards a stimulus, such as the mother's nipple, facilitating latching during breastfeeding. Babinski (A) is a reflex related to the sole of the foot, Moro (C) is a startle reflex, and Stepping (D) involves movements resembling walking. These reflexes do not directly support the latch during breastfeeding. Rooting reflex is the most relevant and essential reflex for successful breastfeeding initiation.

Correct Answer: D

Rationale: The correct answer is D (All of the Above). Epidural anesthesia can increase the risk of urinary retention leading to UTIs. Urinary bladder catheterization can introduce pathogens into the urinary tract. Frequent pelvic examinations can disrupt the natural flora and introduce bacteria. Therefore, all the conditions listed can contribute to an increased risk of urinary tract infections. The other choices (A, B, C) are incorrect because each of them individually presents a risk factor for UTIs, and selecting only one or two choices would not encompass the full range of risk factors that the healthcare professional should include in the teaching.

Correct Answer: A

Rationale: The correct answer is A because chlamydia is commonly treated with a single dose of azithromycin to ensure complete eradication of the infection. This antibiotic is highly effective against chlamydia. Option B is incorrect because both partners need treatment regardless of symptoms. Option C is incorrect as sexual abstinence for 7 days is recommended post-treatment. Option D is incorrect as retesting should be done after 3 months, not 6 months.