A client who is pregnant and has phenylketonuria (PKU) is receiving teaching from a nurse. Which of the following foods should the nurse instruct the client to eliminate from her diet?

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: 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: Moderate lochia rubra. This indicates normal postpartum bleeding 2 days after delivery. Bright red lochia with small clots is expected at this stage. Excessive lochia serosa (B) and scant lochia serosa (D) are not appropriate as serosa typically appears after the first few days postpartum. Light lochia rubra (C) does not accurately describe the amount of bleeding observed in this scenario.

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: B

Rationale: The correct answer is B: Appropriate for gestational age. A newborn is considered appropriate for gestational age when their weight falls within the 10th to 90th percentiles for their gestational age. In this case, the newborn is in the 60th percentile for weight, indicating that the weight is appropriate for the gestational age of 38 weeks. Choice A: Low birth weight is incorrect because a newborn is classified as low birth weight when their weight is below 2,500 g regardless of gestational age. Choice C: Small for gestational age is incorrect because a newborn is classified as small for gestational age when their weight is below the 10th percentile for their gestational age. Choice D: Large for gestational age is incorrect because a newborn is classified as large for gestational age when their weight is above the 90th percentile for their gestational age.

Correct Answer: B

Rationale: The correct answer is B: Ask the client if they have thoughts of harming themselves or their infant. This is the priority because postpartum psychosis poses a risk of harm to the client and the infant. Assessing for suicidal or homicidal ideation is crucial to ensure safety. Choice A may be important but ensuring immediate safety takes precedence. Choice C is important but not the priority. Choice D may provide background information but does not address the immediate safety concern.

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: 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.

Correct Answer: D

Rationale: The correct answer is D because providing reinforcement about infant care when the parent is present can help build the parent's confidence and competence in caring for the newborn, which can enhance parent-infant bonding. By offering support and guidance during interactions with the newborn, the parent can feel more comfortable and connected to the baby. A: Handing the parent the newborn and suggesting they change the diaper may increase their anxiety and not address the underlying issue of bonding. B: Asking the parent why they are anxious and nervous is important but may not directly promote bonding without providing concrete support. C: Telling the parent they will grow accustomed to the newborn does not actively support bonding or address the parent's current concerns. In summary, choice D is the best option as it provides practical assistance and positive reinforcement to help the parent feel more confident in caring for the newborn, ultimately fostering parent-infant bonding.