Foundations and Adult Health Nursing Test Bank

Correct Answer: A

Rationale: Assessing the infant's latch and feeding effectiveness should be prioritized as the initial nursing intervention to address the client's concerns about inadequate milk supply. Poor latch can lead to ineffective milk removal, which may result in decreased milk production. By ensuring the infant is latching correctly and effectively transferring milk, the client's milk supply can be optimized. Education about techniques to increase milk production can be provided following the assessment of feeding effectiveness. Referring to a lactation consultant may be necessary for further evaluation and support if issues persist despite correcting the latch. Supplemental formula feedings should be recommended as a last resort after all other interventions have been attempted and if there are concerns about inadequate nutrition for the infant.

Correct Answer: C

Rationale: In Participative Action Research (PAR), the core idea is to empower the community by involving them in the research process. By actively engaging community members in all stages of the research, they gain a sense of ownership and are empowered to take action based on the research findings. This approach ensures that the solutions generated are relevant, sustainable, and community-driven. Therefore, participation and engagement of the community is the step that will empower the community in PAR, unlike the other options where the focus is on external individuals or entities.

Correct Answer: D

Rationale: Advocacy is the ethical principle that the nurse is responsible for providing all patients with caring attention and information, despite the reaction of the patient. Advocacy involves supporting and speaking up for the patient's best interests, ensuring they receive the care and information they need to make informed decisions about their health and well-being. Providing caring attention and information is essential in advocating for the patient's autonomy and well-being, even if the patient may not initially appreciate or react positively to these efforts.

Correct Answer: B

Rationale: The patient who had a left total hip replacement surgery due to osteoarthritis needs to strictly follow the postoperative teaching of being shown how to gently irrigate the external auditory canal because this instruction is unrelated to a hip replacement surgery. The other options are not relevant to the surgery and patient's condition. Option A about airplane travel, Option C about dizziness, and Option D about hair washing are not appropriate instructions for a patient who had a hip replacement. It is important for healthcare providers to give accurate and relevant postoperative instructions to help the patient recover successfully.

Correct Answer: A

Rationale: Assisting the mother into a hands-and-knees position should be prioritized to facilitate fetal rotation and optimize labor progress in the case of persistent occiput posterior fetal position. This position helps in promoting fetal rotation to a more favorable position for delivery by allowing the baby's head to move into the anterior position. It can help alleviate back pain and may help reduce the duration of labor. This simple maneuver can sometimes correct the malposition without the need for interventions like instrumental delivery. It is a non-invasive and effective technique that can be easily implemented by healthcare providers to support the progression of labor.