Nokea
A client delivered vaginally six hours ago. Which assessment finding can be interpreted as normal?
- A. Temperature 100.0 degrees F
- B. Blood pressure 140/90
- C. Respirations 10
- D. Pulse 90
Correct Answer: A
Rationale: The correct answer is A: Temperature 100.0 degrees F. This finding can be interpreted as normal because a slight increase in body temperature after childbirth is expected due to the physiological changes during labor. A temperature of 100.0 degrees F is within the normal range for postpartum women.
Rationale for why the other choices are incorrect:
B: Blood pressure 140/90 - This blood pressure reading is slightly elevated and may indicate hypertension, which would not be considered normal postpartum.
C: Respirations 10 - A respiratory rate of 10 is abnormally low and could indicate respiratory distress rather than normal postpartum recovery.
D: Pulse 90 - A pulse rate of 90 may be within normal limits, but it is not as indicative of normal postpartum recovery as a slightly elevated temperature would be.
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An 8-year-old child is admitted to a pediatric unit with a fractured femur and is placed in skeletal traction. Which of the following nursing interventions is the most appropriate?
- A. Position the weights securely against the foot of the bed.
- B. Provide small frequent high-fat meals to the child.
- C. Compare pulses on affected site to contralateral side.
- D. Provide diversional activities to minimize the child's movement.
Correct Answer: C
Rationale: The correct answer is C: Compare pulses on affected site to contralateral side. This is the most appropriate nursing intervention because it assesses for any circulatory compromise due to the skeletal traction. Checking pulses helps monitor perfusion distal to the fracture site and ensures early detection of any complications like compartment syndrome. Positioning the weights against the foot of the bed (A) is incorrect as it can cause uneven traction. Providing high-fat meals (B) and diversional activities (D) are irrelevant to the immediate care of the child's fracture.
A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure for the newborn?
- A. Apply a cool pack for 10 minutes to the heel prior to the puncture
- B. Request a prescription for IM analgesic
- C. Use a manual lancet blade to pierce the skin
- D. Place the newborn skin to skin on the mother’s chest
Correct Answer: D
Rationale: The correct answer is D: Place the newborn skin to skin on the mother's chest. This technique, known as kangaroo care, helps minimize pain during procedures by providing comfort, warmth, and security to the newborn. The close physical contact with the mother can reduce stress and promote relaxation, leading to decreased perception of pain. Additionally, the release of oxytocin during skin-to-skin contact can further alleviate discomfort for the newborn.
Applying a cool pack (choice A) may actually increase pain and vasoconstriction, making the heel stick more uncomfortable. Requesting an IM analgesic (choice B) is unnecessary and may expose the newborn to unnecessary medications. Using a manual lancet blade (choice C) can be painful and may not provide the same comfort and pain relief as skin-to-skin contact.
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 assessing a client who is at 30 wks gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider?
- A. Swelling of the face
- B. Varicose veins in the calves
- C. Nonpitting 1+ ankle edema
- D. Hyperpigmentation
Correct Answer: A
Rationale: The correct answer is A: Swelling of the face. Facial swelling in a pregnant woman at 30 weeks gestation could be a sign of preeclampsia, a serious condition characterized by high blood pressure and protein in the urine. It is important to report this finding promptly to the provider for further evaluation and management to prevent complications for both the mother and the baby. Varicose veins in the calves (B) and hyperpigmentation (D) are common in pregnancy but are not urgent issues requiring immediate reporting. Nonpitting 1+ ankle edema (C) is a common finding in pregnancy but is not as concerning as facial swelling. Make sure to report any change in the severity of edema.
A nurse is discussing the use of condoms with a female client. Which of the following statements by client represents a need for further teaching?
- A. My partner will put the condom on while his penis is erect.
- B. I will remove the condom 30 minutes after intercourse.
- C. My partner should leave an empty space at the tip.
- D. I can use spermicidal gels or creams to increase effectiveness.
Correct Answer: B
Rationale: The correct answer is B because removing the condom 30 minutes after intercourse is incorrect. Condoms should be removed immediately after ejaculation to prevent leakage or spillage of semen. Leaving the condom on for too long increases the risk of pregnancy and STIs. Choice A is correct as putting the condom on while the penis is erect is the proper way to ensure it fits securely. Choice C is also correct as leaving a small space at the tip allows room for semen collection. Choice D is incorrect because spermicidal gels or creams are not recommended with condoms as they can cause irritation and may not increase effectiveness.