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 because it demonstrates the client's understanding that a second vaccination is needed, which is crucial for developing adequate immunity against varicella. This statement shows comprehension of the vaccination schedule and the importance of completing the series for full protection. Option A is incorrect as it suggests the need for a second vaccination but lacks conviction. Option C is incorrect because it only states the purpose of the vaccine without addressing the need for a second dose. Option D is incorrect as it mentions testing for immunity status, which is not typically necessary after receiving the varicella vaccine.

Correct Answer: B

Rationale: The correct answer is option B: Palpate the fundus of the uterus. This technique helps the nurse identify the fetal lie by feeling for the position of the baby's head or buttocks at the top of the uterus. By palpating the fundus, the nurse can determine whether the baby is in a vertex (head down) or breech (head up) position. This method is effective in assessing the fetal lie as it provides direct information about the baby's orientation within the uterus. Option A is incorrect because applying palms to the sides of the uterus does not specifically help identify the fetal lie. Option C is incorrect as grasping the lower uterine segment does not provide information on the fetal lie. Option D is incorrect because standing facing the client's feet with fingertips outlining cephalic prominence is not a technique used to determine fetal lie.

Correct Answer: C

Rationale: The correct answer is C: Completely empty each breast at each feeding or use a pump. This is the correct response because it helps to ensure effective milk removal, which is crucial for treating mastitis. By fully emptying the breast, the nurse can prevent milk stasis and promote healing. A: Limiting the time the infant nurses on each breast may lead to incomplete milk removal, worsening the condition. B: Nursing only on the unaffected breast does not address the issue of milk stasis in the affected breast and may lead to further complications. D: Wearing a tight-fitting bra can exacerbate mastitis by restricting milk flow and increasing discomfort.

Correct Answer: A

Rationale: The correct answer is A: Peanut butter. Phenylketonuria (PKU) is a metabolic disorder where the body can't process phenylalanine found in protein foods. Peanut butter is high in protein and contains phenylalanine, so it should be eliminated from the client's diet. Potatoes, apple juice, and broccoli are low in protein and do not contain high levels of phenylalanine, so they do not need to be eliminated. It is crucial for the client to avoid foods high in phenylalanine to prevent the buildup of toxic levels in the body, which can lead to serious health issues.

Correct Answer: C

Rationale: The correct answer is C: Sunken fontanels. This finding indicates dehydration in the infant, which can be a serious complication requiring immediate intervention. Dehydration can lead to further elevation of bilirubin levels and potential neurological complications. Reporting this to the charge nurse is crucial for prompt assessment and intervention. Incorrect choices: A: Conjunctivitis - Although important, it is not a priority over a sign of dehydration. B: Bronze skin discoloration - This may be a common side effect of phototherapy and does not indicate an urgent issue. D: Maculopapular skin rash - While it should be monitored, it does not take precedence over a sign of dehydration.

Correct Answer: C

Rationale: Rationale: C is correct because keeping the nipple full of formula throughout the feeding helps prevent the baby from swallowing air, reducing the risk of gas and colic. A is incorrect because burping should be done mid-feeding. B is incorrect because newborns should be held in an upright position while feeding to prevent choking. D is incorrect because unused formula should be discarded within 1-2 hours, not refrigerated.

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: Wide skull sutures. Small for gestational age (SGA) newborns may have wide skull sutures due to reduced skull growth in utero. This is because their growth was restricted, leading to smaller head size and delayed closure of skull sutures. A, B, and C are incorrect: A: Moist skin is not a typical finding associated with being small for gestational age. B: Protruding abdomen is more commonly seen in conditions like gastroschisis or omphalocele, not necessarily SGA. C: Gray umbilical cord color is not specifically linked to being small for gestational age.