A postpartum client expresses concerns about breastfeeding and worries about inadequate milk supply. What nursing intervention should be prioritized to address the client's concerns?

Correct Answer: A

Rationale: Assessing the infant's latch and feeding effectiveness should be prioritized as the initial nursing intervention to address the client's concerns about inadequate milk supply. Poor latch can lead to ineffective milk removal, which may result in decreased milk production. By ensuring the infant is latching correctly and effectively transferring milk, the client's milk supply can be optimized. Education about techniques to increase milk production can be provided following the assessment of feeding effectiveness. Referring to a lactation consultant may be necessary for further evaluation and support if issues persist despite correcting the latch. Supplemental formula feedings should be recommended as a last resort after all other interventions have been attempted and if there are concerns about inadequate nutrition for the infant.

Correct Answer: C

Rationale: The presentation described in the question (sensation of fullness and pressure in the left ear, hearing loss, occasional tinnitus, retracted tympanic membrane with decreased mobility on pneumatic otoscopy) is suggestive of serous otitis media, also known as otitis media with effusion. Serous otitis media occurs when fluid accumulates in the middle ear without signs of infection. This buildup of fluid in the middle ear space can cause the tympanic membrane to retract and reduce its mobility on pneumatic otoscopy.

Correct Answer: A

Rationale: Administering systemic analgesia, such as pain medications or anesthesia, before the wound debridement procedure is the most effective way to minimize patient discomfort. These medications will help manage and reduce the pain experienced by the patient during the procedure, making it more tolerable for them. Topical anesthetic cream may provide some localized relief but may not be sufficient for significant pain management during a wound debridement procedure. Using sharp debridement techniques or performing the procedure quickly may help reduce manipulation or duration, respectively, but these actions alone may not adequately address the patient's pain and discomfort. Administering systemic analgesia ensures that the patient's overall pain is managed, promoting a more comfortable and successful wound debridement procedure.

Correct Answer: C

Rationale: The suicide of her mother is the most probable historical data that led to post-traumatic stress disorder. Experiencing the suicide of a close family member, especially a parent, can be an extremely traumatic event that can have long-lasting psychological effects. Witnessing or dealing with such a tragic loss can lead to feelings of helplessness, depression, guilt, and intense emotional distress, all of which are common in individuals with post-traumatic stress disorder (PTSD). This significant and distressing event could have a profound impact on the individual's mental health and well-being, contributing to the development of PTSD symptoms such as intrusive memories, avoidance behaviors, negative mood alterations, and changes in arousal or reactivity.

Correct Answer: D

Rationale: When determining the existence of malpractice, intent is not considered as a factor. Malpractice typically involves unintentional actions or negligence rather than a deliberate intent to cause harm. The key factors that are usually considered in a malpractice case include duty (a legal obligation to provide a certain standard of care), causation (the link between the provider's actions and the patient's injury), and the existence of an injury resulting from the provider's actions or omissions. Intent does not play a direct role in malpractice cases, as they are focused on the standard of care provided by the healthcare professional and the harm caused as a result.

Correct Answer: D

Rationale: In the situation described, where the client experienced a prolonged labor and instrumental delivery, there may be physical and emotional factors impacting breastfeeding success. A lactation consultant is a specialized healthcare provider who can assess the client's breastfeeding difficulties, offer individualized support, and provide guidance on techniques to overcome challenges such as latch issues, positioning problems, and milk supply concerns. Referring the client to a lactation consultant will help ensure that she receives expert assistance tailored to her specific needs, thereby increasing the likelihood of successful breastfeeding. This proactive approach focuses on addressing the root causes of breastfeeding difficulties and supporting the client in achieving her breastfeeding goals.

Correct Answer: B

Rationale: Type I IgE-mediated immediate hypersensitivity reactions, such as anaphylaxis, are promptly managed with epinephrine. Epinephrine is the first-line treatment for anaphylaxis as it helps counteract the severe symptoms by relaxing the muscles in the airways, constricting blood vessels, and decreasing swelling. It acts quickly to reverse the potentially life-threatening effects of the allergic reaction and is crucial in managing anaphylaxis effectively. Other medications like antihistamines (e.g., diphenhydramine) and corticosteroids may be used as adjuncts, but epinephrine remains the primary treatment for immediate hypersensitivity reactions.

Correct Answer: B

Rationale: The patient who had a left total hip replacement surgery due to osteoarthritis needs to strictly follow the postoperative teaching of being shown how to gently irrigate the external auditory canal because this instruction is unrelated to a hip replacement surgery. The other options are not relevant to the surgery and patient's condition. Option A about airplane travel, Option C about dizziness, and Option D about hair washing are not appropriate instructions for a patient who had a hip replacement. It is important for healthcare providers to give accurate and relevant postoperative instructions to help the patient recover successfully.

Correct Answer: C

Rationale: It is not important for Myra to listen to the tape recordings only when she feels motivated or productive. In a nurse-patient interaction relationship, listening to tape recordings promptly (Choice A) is crucial because it ensures that any important information or cues are not missed or forgotten. Additionally, noting voice tone and inflection (Choice B) and observing pauses (Choice D) are essential for understanding the nuances and emotions conveyed during the interaction, which can be crucial in effective communication. Listening based on motivation may lead to delays and hamper the timely analysis and understanding of the interactions. Hence, it is important for Myra to prioritize active and focused listening to the tape recordings, regardless of her current motivation levels.