A 2-day postpartum mother who
is breastfeeding asks, "Why do I
feel this tingling in my breasts
after the baby sucks for a few
minutes?" Which information
should the nurse provide?
A. This feeling occurs during
fe
...
A 2-day postpartum mother who
is breastfeeding asks, "Why do I
feel this tingling in my breasts
after the baby sucks for a few
minutes?" Which information
should the nurse provide?
A. This feeling occurs during
feeding with a breast infection.
B. This sensation occurs as breast
milk moves to the nipple.
C. The baby does not have good
latch-on.
D. The infant is not positioned
correctly.
B. This sensation occurs as breast
milk moves to the nipple.
Rationale:
When the mother's milk comes in,
usually 2 to 3 days after delivery,
women often report they feel a
tingling sensation in their nipples (B)
when let-down occurs. (A, C, and D)
provide inaccurate information.
2
.
A 40-year-old office worker who is
at 36 weeks' gestation presents to
the occupational health clinic
complaining of a pounding
headache, blurry vision, and
swollen ankles. Which
intervention should the nurse
implement first?
A. Check the client's blood
pressure.
B. Teach her to elevate her feet
when sitting.
C. Obtain a 24-hour diet history
to evaluate for the intake of salty
foods.
D. Assess the fetal heart rate.
A. Check the client's blood pressure.
Rationale:
The blood pressure (A) should be
assessed first. Preeclampsia is a
multisystem disorder, and women
older than 35 years and have chronic
hypertension are at increased risk.
Classic signs include headache,
visual changes, edema, recent rapid
weight gain, and elevated blood
pressure. (B, C, and D) can be done if
the blood pressure is normal.
3
.
A 50-year-old man arrives at the
clinic with complaints of pain on
ejaculation. Which action should
the nurse implement?
A. Teach the client testicular selfexamination (TSE).
B. Assess for the presence of blood
in the urine.
C. Ask about scrotal pain or blood
in the semen.
C. Ask about scrotal pain or blood in
the semen.
Rationale:
Orchitis is an acute testicular
inflammation resulting from recurrent
urinary tract infection, recurrent
sexually transmitted disease (STD),
or an indwelling urethral urinary
catheter causing pain on ejaculation,
scrotal pain, blood in the semen, and
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