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NEW QUESTION 21
A mother who is breast-feeding her newborn asks the RN, "How can I express milk from my breasts manually?" The RN tells her that the correct method for manual milk expression includes using the thumb and the index finger to:

A. Slide the thumb and index finger forward from the outer border of the areola toward the end of the nippleB. Compress and release each breast at the outer border of the areolaC. Alternately compress and release each nippleD. Roll the nipple and gently pull the nipple forward

Answer: B

Explanation:
Explanation/Reference:
Explanation:
(A) Manipulation of nipples will cause soreness and trauma. (B) Pulling the nipples will cause discomfort and soreness. (C) Sliding the thumb and index finger forward over the nipple will cause soreness. (D) The best method to express milk from the breast is to position the thumb and index finger at the outer border of the areola and compress. This is the location of the milk sinuses.

 

NEW QUESTION 22
A 14-year-old boy has a head injury with laceration of his scalp over his ear. The nurse should call the physician to report:

A. Headache that is unresponsive to acetaminophen (Tylenol)B. Temperature rise to 102°F rectallyC. Pulse rate ranges between 68 bpm and 76 bpmD. Blood pressure increase from 100/80 to 115/85 after lunch

Answer: B

Explanation:
Section: Questions Set F
Explanation:
(A) This change in blood pressure may not be significant and does not indicate a widening pulse pressure, a late sign of increased ICP. It is important to continue to monitor for change in blood pressure. (B) Acetaminophen may be ineffective in relieving headache after head injury. Stronger analgesics are contraindicated because they mask neurological signs and may depress the CNS. (C) Pulse rates between 68 bpm and 76 bpm are within normal limits for a 14-year-old child. It is important to monitor for a consistent drop in pulse rate, which is a late sign of increasing ICP. (D) An elevated temperature is abnormal and requires further assessment and medical intervention. The temperature may be unrelated to the head injury, but CNS infection is serious and difficult to control.

 

NEW QUESTION 23
After instructing a female client on circumcision care, the nursery nurse asks her to restate some of the key points covered. Which statement shows that the client will properly care for her son's circumcision?

A. "I'll keep a close watch on it for a day or two."B. "I'll make sure that I report any drainage around where they operated."C. "I'll make sure I soak the gauze with warm water first, before I take it off each time."D. "I'll apply alcohol to the area daily to clean it and prevent any infection."

Answer: C

Explanation:
Explanation/Reference:
Explanation:
(A) Before petrolatum gauze is removed, it should be soaked with warm water to prevent trauma to adherent tissues. (B) A yellow exudate often forms normally over the surgical site. Only if it becomes foul- smelling and purulent would it need to be reported. (C) Alcohol should never be used on the site; this would be extremely painful to the infant. (D) Special care and observance should continue until the site is completely covered with clean, pink granulation tissue, which could take 7-10 days.

 

NEW QUESTION 24
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