Choice A rationale

Leukorrhea is a common and normal occurrence in pregnancy due to increased estrogen production and greater blood flow to the vaginal area. It is usually a thin, white discharge and not a cause for concern unless accompanied by itching, burning, or an unusual odor.

Choice B rationale

Excessive salivation, also known as ptyalism, can occur during pregnancy, particularly in the first trimester. It is linked to hormonal changes and is not typically harmful, though it may be uncomfortable for the patient.

Choice C rationale

Darkening of the skin on the face, known as melasma or chloasma, is common during pregnancy and is due to increased pigmentation from hormonal changes. It typically resolves postpartum and is not harmful.

Choice D rationale

Epigastric pain in a pregnant client at 33 weeks gestation can be a sign of preeclampsia, a serious condition characterized by high blood pressure and damage to other organs. It requires immediate medical attention to prevent complications for both the mother and baby.

Choice A rationale

Delay in initiating breastfeeding can occur after a cesarean birth due to the effects of anesthesia, postoperative recovery, and the need for medical monitoring, which can delay the mother’s ability to start breastfeeding.

Choice B rationale

Routine use of intubation equipment is not standard practice during a cesarean birth. Intubation is typically reserved for patients who require general anesthesia or have complications that necessitate airway management.

Choice C rationale

The need for an indwelling urinary catheter is common during a cesarean birth. It helps to keep the bladder empty and out of the way during the procedure and is usually placed after anesthesia and removed shortly after the surgery.

Choice D rationale

Management of postpartum pain is an important topic to discuss with clients undergoing cesarean birth. Postoperative pain management may include medications and non-pharmacological methods to ensure comfort and aid in recovery.

Choice A rationale

Giving glucose water after feedings is not recommended for newborns undergoing phototherapy. Breastfeeding or formula feeding should be continued to provide adequate nutrition and hydration.

Choice B rationale

Instructing the client to avoid breastfeeding during treatment is not necessary. Breastfeeding should continue to promote bonding, provide nutrition, and help with the infant's hydration and bilirubin excretion.

Choice C rationale

Monitoring intake and output is crucial for a newborn receiving phototherapy to ensure proper hydration and assess the effectiveness of the treatment in lowering bilirubin levels.

Choice D rationale

Applying lotions and ointments throughout the treatment is not recommended, as they can interfere with the effectiveness of phototherapy. The skin should be clean and dry to maximize exposure to the phototherapy light.

Choice A rationale

Gaining 2 pounds per week throughout the rest of pregnancy is excessive and not recommended. Normal weight gain is approximately 1 pound per week in the second and third trimesters.

Choice B rationale

Dieting during pregnancy can lead to inadequate nutrient intake for both the mother and the developing fetus. It is essential to focus on a balanced diet rather than trying to lose weight.

Choice C rationale

Meeting with a dietitian can help the client assess their nutritional needs and develop a healthy eating plan to support their pregnancy, ensuring both maternal and fetal health.

Choice D rationale

Eating an additional 700 calories per day is too high. Generally, an additional 300-500 calories per day is recommended during the second and third trimesters to support pregnancy. .

Choice A rationale

An indwelling urinary catheter can increase the risk of falls because it may cause discomfort and restricted mobility, leading the client to move awkwardly or lose balance.

Choice B rationale

While a second-degree perineal laceration might cause pain and limited mobility, it doesn't usually contribute as significantly to fall risk as an indwelling catheter.

Choice C rationale

Saturating a perineal pad every 5 to 6 hours may indicate heavy postpartum bleeding, but it isn't directly related to fall risk. The concern here would be more about monitoring for hemorrhage rather than falls.

Choice D rationale

Breast engorgement causes discomfort and pain but doesn't directly affect a client's mobility or balance, making it less likely to increase fall risk.

Choice A rationale

Holding the newborn during the initial visit may make the older sibling feel left out or jealous. Encouraging involvement with the new baby may be more beneficial.

Choice B rationale

Spending individual time with the older sibling helps them feel valued and ensures they do not feel neglected, facilitating better acceptance of the newborn.

Choice C rationale

Having the older sibling purchase a gift for the newborn can create a positive association, but it is less impactful than ensuring individual time and attention.

Choice D rationale

Postponing the introduction until discharge can increase feelings of jealousy or resentment, as the older sibling might feel excluded from the new family dynamic during a crucial time.

Choice A rationale

Suctioning the mouth and nose ensures that the airway is clear of any meconium-stained fluid, which can cause respiratory issues in the newborn if inhaled.

Choice B rationale

While skin-to-skin contact is beneficial for bonding and temperature regulation, ensuring the airway is clear is a higher immediate priority.

Choice C rationale

Placing the newborn under a radiant warmer helps maintain body temperature but is secondary to ensuring the airway is clear of meconium-stained fluid.

Choice D rationale

Tactile stimulation is important for encouraging breathing, but first ensuring the airway is clear takes precedence.

Choice A rationale

A shrill cry may indicate distress but isn't specifically related to hypoglycemia in newborns.

Choice B rationale

Weak peripheral pulses are more commonly associated with circulatory or cardiac issues rather than hypoglycemia.

Choice C rationale

Yellowish skin suggests jaundice, which is due to elevated bilirubin levels, not hypoglycemia.

Choice D rationale

Hypotonia, or decreased muscle tone, can be a sign of hypoglycemia in newborns, indicating a need to check blood glucose levels.

Choice A rationale

Rear-facing car seats are safer for infants and toddlers because they provide better support for their head, neck, and spine in the event of a collision. The American Academy of Pediatrics recommends keeping children in rear-facing seats until they are at least 2 years old or until they reach the highest weight or height allowed by the manufacturer.

Choice B rationale

A four-point harness is not sufficient for securing a baby in a car seat. A five-point harness, which includes two shoulder straps, two hip straps, and one crotch strap, provides more secure and effective restraint for infants.

Choice C rationale

The shoulder harness should be positioned in the slots at or below the baby's shoulders, not above, to ensure proper fit and restraint. Placing the harness above the shoulders can result in improper restraint and increased risk of injury in an accident.

Choice D rationale

The correct angle for a rear-facing car seat is typically 45 degrees, not 30 degrees. A 45-degree angle ensures the baby's airway remains open, preventing the head from falling forward and potentially causing breathing difficulties.

Choice A rationale

Feeding from only one breast can lead to engorgement and a decrease in milk supply in the affected breast. It is important to continue breastfeeding from both breasts, even if one is infected.

Choice B rationale

Discarding milk is not necessary and can lead to a decrease in milk supply. The infection does not harm the baby, and breastfeeding helps to drain the breast and clear the infection.

Choice C rationale

Moist heat can help to increase blood flow and promote healing in the affected breast. Applying warm compresses or taking warm showers can help to reduce pain and inflammation associated with mastitis.

Choice D rationale

While staying hydrated is important for overall health, there is no specific requirement to drink at least 1500 milliliters of fluid per day for mastitis. Adequate fluid intake should be maintained, but there is no direct correlation with resolving the infection.