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A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for misoprostol. Which of the following instructions should the nurse include in the teaching?
- A. I can administer oxytocin 4 hours after the insertion of the medication
- B. You will need a full bladder prior to the insertion of the medication
- C. Remain in a side-lying position for 15 minutes after the medication is inserted
- D. An antacid will be given 20 minutes prior to the insertion of the medication
Correct Answer: C
Rationale: The correct answer is C: Remain in a side-lying position for 15 minutes after the medication is inserted. This instruction is important because misoprostol can cause uterine contractions leading to potential discomfort or cramping. By remaining in a side-lying position, the client can help the medication remain in the desired location near the cervix, enhancing its effectiveness. This position also helps reduce the risk of the medication leaking out prematurely and ensures optimal absorption.
Choice A is incorrect because oxytocin is not typically administered shortly after misoprostol due to the potential for excessive uterine stimulation. Choice B is incorrect as a full bladder is not necessary for the insertion of misoprostol. Choice D is incorrect as an antacid is not typically required prior to the insertion of misoprostol.
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A nurse is reinforcing home care instructions with the parents of a 5-year-old child who has acute bronchitis. In order to prevent the transmission of the virus, which of the following should the nurse include in the instructions?
- A. Isolate the child in a bedroom separated from the rest of the family.
- B. Teach the child to wash his hands after coughing secretions into a tissue.
- C. Serve food to the child on disposable dishes with plastic utensils.
- D. Have the child wear a mask whenever leaving the bedroom.
Correct Answer: B
Rationale: The correct answer is B: Teach the child to wash his hands after coughing secretions into a tissue. This is because handwashing is one of the most effective ways to prevent the transmission of viruses, including acute bronchitis. By washing hands after coughing into a tissue, the child can reduce the spread of germs to others.
Choice A is incorrect because isolating the child in a bedroom may not be practical or necessary for preventing transmission. Choice C is incorrect as there is no evidence to support that serving food on disposable dishes with plastic utensils prevents transmission of the virus. Choice D is incorrect as wearing a mask whenever leaving the bedroom may not be necessary if proper hand hygiene is practiced.
During the first twelve hours following a normal vaginal delivery, the client voids 2,000 mL of urine. How should the nurse interpret this finding?
- A. Urinary tract infection
- B. High output renal failure
- C. Excessive use of IV fluids during delivery
- D. Normal diuresis after delivery
Correct Answer: D
Rationale: The correct interpretation is D: Normal diuresis after delivery. After childbirth, diuresis is common due to the body eliminating excess fluid retained during pregnancy. This process helps reduce swelling and aids in returning to pre-pregnancy state. Voiding 2,000 mL in the first twelve hours is within the expected range for postpartum diuresis. Choices A, B, and C are incorrect as they do not align with the typical physiologic response to childbirth. Urinary tract infection and high output renal failure would present with other symptoms, while excessive IV fluid use would not explain the timing or volume of urine output.
Two days after delivery, a postpartum client prepares for discharge. What should the nurse teach her about lochia flow?
- A. Lochia does change color but goes from lochia rubra (bright red) on days 1-3, to lochia serosa (pinkish brown) on days 4-9, to lochia alba (creamy white) days 10-21.
- B. Numerous clots are abnormal and should be reported to the physician.
- C. Saturation of the perineal pad is considered abnormal and may indicate postpartum hemorrhage.
- D. Lochia normally lasts for about 21 days, and changes from a bright red, to pinkish brown, to creamy white.
Correct Answer: D
Rationale: The correct answer is D. Lochia normally lasts for about 21 days, and changes from a bright red, to pinkish brown, to creamy white. This is accurate information regarding the typical progression of lochia flow postpartum. Lochia rubra is the initial discharge, followed by lochia serosa, and finally, lochia alba. This teaching is important for the client to understand what to expect in terms of postpartum bleeding.
Choice A is incorrect as it inaccurately describes the color changes of lochia. Choice B is incorrect because the presence of numerous clots is common in the immediate postpartum period and not necessarily abnormal. Choice C is incorrect as perineal pad saturation is expected initially, and significant saturation may not always indicate hemorrhage.
A nurse is caring for an adolescent with inadequate weight gain.
- A. "Identify food preferences high in complex carbohydrates."'
- B. "Identify food preferences high in saturated and unsaturated fats."'
- C. "Identify food preferences high in calcium and protein."'
- D. "Identify food preferences high in calories."'
Correct Answer: C
Rationale: The correct answer is C: "Identify food preferences high in calcium and protein." Inadequate weight gain in adolescents can be due to lack of essential nutrients like calcium and protein for growth and development. Calcium is crucial for bone health, while protein is essential for muscle development. Both are important for overall growth. Choices A and D focus on carbohydrates and calories, which are important but not the primary nutrients needed for weight gain in this scenario. Choice B suggests high intake of saturated and unsaturated fats, which can be detrimental to overall health if consumed in excess. Therefore, identifying food preferences high in calcium and protein is the most appropriate choice to address inadequate weight gain in the adolescent.
A woman enters the birthing center in active labor. She tells the nurse that her membranes ruptured 26 hours ago. The nurse immediately takes the client's vital signs. Which is the rationale for the nurse's actions?
- A. Pulse rates rise the longer the membranes are ruptured
- B. Respiratory rates decrease due to lack of fluid in the uterus
- C. Prolonged rupture of membranes can lead to transient hypertension
- D. Infection is a complication of prolonged rupture of membranes
Correct Answer: D
Rationale: The correct answer is D. When the membranes rupture, it increases the risk of infection as it provides a direct pathway for bacteria to enter the uterus. Taking vital signs is crucial to monitor for signs of infection such as fever, tachycardia, and hypotension. Elevated temperature and increased heart rate can indicate an infection. Choice A is incorrect because pulse rate may not necessarily rise with prolonged rupture of membranes. Choice B is also incorrect as respiratory rates are not directly affected by ruptured membranes. Choice C is incorrect as prolonged rupture can lead to infection rather than transient hypertension.