Following this type of birth, the nurse should monitor the client for hemorrhage and monitor the newborn for facial nerve palsy.
What additional care should the nurse consider?
Administering prophylactic antibiotics to prevent infection.
Assessing for signs of jaundice in the newborn.
Monitoring the client's vital signs for stability.
Educating the client on breastfeeding techniques.
The Correct Answer is B
Choice A rationale
Administering prophylactic antibiotics is essential when there is infection risk, but this intervention is not directly related to managing hemorrhage or neonatal nerve palsy.
Choice B rationale
Jaundice assessment is critical for newborns with facial bruising or cephalohematoma, as bilirubin levels may rise due to blood breakdown in the localized hematoma.
Choice C rationale
Monitoring vital signs ensures maternal stability, though it does not directly address hemorrhage risk or neonatal complications like nerve palsy.
Choice D rationale
Educating the client on breastfeeding techniques provides essential support but does not focus on managing cephalohematoma-related neonatal conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
Handwashing before breastfeeding minimizes the risk of pathogen transmission, protecting both the mother and infant. This practice is critical for managing mastitis, which can be complicated by infection.
Choice B rationale
Proper latching techniques reduce nipple trauma, aiding in the prevention of further mastitis development. Correct latching also facilitates effective milk drainage, minimizing milk stasis and associated risks.
Choice C rationale
Alternating breastfeeding with formula feeding reduces milk removal, increasing the risk of milk stasis and infection. Breastfeeding exclusively, if tolerated, is vital for resolving mastitis and maintaining milk supply.
Choice D rationale
Allowing nipples to air dry promotes healing of any nipple trauma. Moist environments facilitate bacterial growth, complicating mastitis recovery. Air drying reduces infection risk and improves comfort.
Correct Answer is C
Explanation
Choice A rationale
Potassium intake does not directly affect fibrocystic breast changes or menstruation-related breast discomfort. Fibrocystic changes are influenced by hormonal fluctuations, not electrolyte levels, requiring measures targeting hormonal effects.
Choice B rationale
Increasing fluid intake to 3 liters per day does not specifically alleviate fibrocystic breast discomfort during menstruation. Excess fluid can exacerbate swelling, leading to increased breast tenderness rather than relief.
Choice C rationale
Alcohol consumption can worsen fibrocystic breast discomfort due to its estrogen-modulating effects, which may exacerbate hormonal fluctuations during menstruation, increasing breast pain and sensitivity.
Choice D rationale
Fiber intake does not directly influence fibrocystic breast discomfort or hormonal activity associated with menstruation. Limiting fiber intake is unrelated to managing symptoms of hormonal-induced breast changes.
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