The triage nurse is interviewing a client, 19 years old, unmarried, who states, 'I felt a hard thing on the lip of my vagina this morning. It doesn’t hurt.' Which of the following questions is most important for the nurse to ask at this time?

Correct Answer: B

Rationale: The correct answer is B) "Do you ever have unprotected intercourse?" This question is the most important because the client's report of feeling a hard thing on her vaginal lip could indicate a sexually transmitted infection (STI) like a genital wart, which can be transmitted through unprotected sexual intercourse. By asking about unprotected intercourse, the nurse can assess the client's risk for STIs and provide appropriate education on safe sex practices and STI prevention. Option A) "Have any of your partners ever hurt you?" is incorrect because it does not address the client's current symptom of a hard thing on her vaginal lip and focuses more on a history of partner violence. Option C) "Have you ever had a baby?" is irrelevant to the client's presenting concern and does not address the potential STI risk. Option D) "Do you think you may be pregnant?" is also not relevant to the client's complaint of a hard thing on her vaginal lip. While pregnancy testing may be important in some cases, it is not the priority in this situation where an STI is suspected. In an educational context, this question highlights the importance of thorough assessment and critical thinking in identifying potential health risks in high-risk populations like young, sexually active individuals. It emphasizes the need for nurses to ask targeted questions to gather essential information for effective care and intervention.

Correct Answer: D

Rationale: The correct answer is D) Kernicterus. Kernicterus is a condition caused by severe hyperbilirubinemia leading to bilirubin deposition in the brain, which can result in significant neurological damage, including hearing loss. In newborns, high levels of unconjugated bilirubin can cross the blood-brain barrier due to an immature liver function, leading to kernicterus if left untreated. Option A) Necrotizing enterocolitis is a condition involving intestinal inflammation and necrosis, which does not directly lead to hearing loss in a child. Option B) Hypoglycemia, while a serious condition in newborns, does not typically result in hearing loss as a direct complication. Option C) Bronchopulmonary dysplasia is a lung disease seen in premature infants and is not associated with causing hearing loss in a child. Educationally, understanding the pathophysiology of kernicterus and its association with hyperbilirubinemia is crucial for healthcare professionals caring for newborns. Early recognition, monitoring, and treatment of hyperbilirubinemia can prevent complications like kernicterus and its long-term consequences, including hearing loss. This knowledge is essential for nurses, midwives, and physicians working in neonatal care settings to ensure optimal outcomes for newborns.

Correct Answer: D

Rationale: The correct answer is option D: "Lanolin cream applied after each feeding will help you to heal." This option is correct because lanolin cream is a safe and effective treatment for cracked and bleeding nipples in breastfeeding mothers. Lanolin helps to soothe and moisturize the skin, promoting healing without the need to interrupt breastfeeding. Option A is incorrect because while it is important for the client to be seen by a healthcare provider, it is not necessary to do so immediately in this case as the issue can be managed at home. Option B is incorrect as there is no need for the mother to pump and dump her milk for a week due to the presence of blood. Breast milk is still safe for the baby to consume even if the mother's nipples are bleeding. Option C is incorrect because using hydrogen peroxide on the nipples can be too harsh and drying, potentially causing further irritation and delaying healing. In an educational context, it is crucial for nurses and healthcare providers to have a good understanding of common issues faced by breastfeeding mothers and appropriate interventions to support them. Providing accurate information and guidance can help mothers overcome challenges and continue breastfeeding successfully.

Correct Answer: D

Rationale: In a postpartum client following a forceps delivery, monitoring for infection is crucial due to the increased risk of developing infections such as endometritis or wound infections. This risk is higher in forceps deliveries due to the potential tissue trauma associated with the use of forceps during delivery. Option A, placental abruption, is not typically a complication of forceps delivery but rather a risk during pregnancy or labor itself. Option B, seizure, may be related to conditions like eclampsia but is not directly associated with forceps delivery. Option C, idiopathic thrombocytopenia, is not a common complication following forceps delivery. Understanding the specific risks and complications associated with different modes of delivery is essential for nurses caring for postpartum clients. By monitoring for signs of infection, nurses can promptly intervene and provide appropriate treatment, promoting optimal recovery and outcomes for the mother.

Correct Answer: C

Rationale: In this scenario, option C, "The baby's lower lip is curled under," indicates that the baby is poorly latched. This is because a proper latch involves the baby taking in a good portion of the areola along with the nipple, ensuring effective milk transfer and preventing nipple soreness or damage. When the baby's lower lip is curled under, it may result in shallow latch, leading to ineffective feeding and potential issues for both the baby and the mother. Option A, "The baby swallows after every suckle," is incorrect because swallowing after every suckle is a positive sign of effective breastfeeding and milk transfer. Option B, "The baby's body is facing the mother's body," is also incorrect as proper positioning involves the baby facing the breast directly for a good latch. Option D, "The baby is lying at the level of the mother's breasts," is not directly related to latch assessment but rather refers to positioning, which may vary depending on the comfort of the mother and the baby. Educationally, understanding the signs of a good latch is crucial for promoting successful breastfeeding, ensuring adequate nutrition for the newborn, and preventing issues like poor weight gain or nipple pain for the mother. Nurses play a key role in supporting breastfeeding mothers by providing guidance on proper latch techniques and troubleshooting any difficulties that may arise during breastfeeding sessions.