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A nurse is planning care for a client who is 1 hr postpartum and has peripartum cardiomyopathy. Which of the following actions should the nurse plan to take?
- A. Obtain a prescription for misoprostol.
- B. Assess blood pressure twice daily.
- C. Restrict daily oral fluid intake.
- D. Administer an IV bolus of lactated Ringer's.
Correct Answer: B
Rationale: The correct answer is B: Assess blood pressure twice daily. This is crucial as peripartum cardiomyopathy can lead to heart failure and hypertension, affecting the client's blood pressure. Monitoring blood pressure twice daily allows for early detection of any changes and timely intervention. Obtaining a prescription for misoprostol (A) is not indicated as it is used for preventing gastric ulcers, not related to peripartum cardiomyopathy. Restricting oral fluid intake (C) may worsen the client's condition as adequate hydration is important for cardiac function. Administering an IV bolus of lactated Ringer's (D) could potentially worsen fluid overload and exacerbate heart failure.
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A nurse is assessing a client who is at 6 weeks of gestation and adheres to a vegan diet. Which of the following questions should the nurse ask to assess the client’s dietary intake?
- A. How much protein do you eat in a day?
- B. Are you taking a Vitamin C supplement?
- C. Have you considered eating shellfish?
- D. When was the last time you ate meat?
Correct Answer: A
Rationale: The correct answer is A: How much protein do you eat in a day? This question is important because a vegan diet may lack sufficient protein, which is crucial for fetal development. Protein intake is a key concern for pregnant vegans to ensure adequate nutrition for both the mother and the developing fetus.
Choice B is incorrect because Vitamin C deficiency is not typically a major concern for pregnant vegans. Choice C is incorrect as shellfish is not suitable for a vegan diet. Choice D is incorrect as asking about eating meat is not relevant to someone following a vegan diet.
A nurse is providing teaching about increasing dietary fiber to an antepartum client who reports constipation. Which of the following food selections has the highest fiber content per cup?
- A. Oatmeal
- B. Cabbage
- C. Asparagus
- D. Lentils
Correct Answer: D
Rationale: The correct answer is D: Lentils. Lentils have a high fiber content, providing about 15.6 grams of fiber per cooked cup. This high fiber content can help alleviate constipation in the antepartum client. Oatmeal, cabbage, and asparagus have lower fiber content compared to lentils. Oatmeal contains around 4 grams of fiber per cup, cabbage has about 2 grams per cup, and asparagus provides about 3 grams of fiber per cup. Therefore, lentils offer the highest fiber content per cup among the options provided, making them the most suitable choice to address constipation in the antepartum client.
Which of the following findings should the nurse report to the provider? (Select all that apply.)
- A. Coombs test result
- B. Mucous membrane assessment
- C. Intake and output
- D. Respiratory rate
- E. Head assessment finding
- F. Heart rate
- G. Sclera color
Correct Answer: A,B,C,G
Rationale: The correct answers are A, B, C, and G. A Coombs test result should be reported as it indicates the presence of antibodies that can cause hemolytic anemia. Mucous membrane assessment is crucial for detecting hydration status and oxygenation. Intake and output monitoring helps assess kidney function and fluid balance. Sclera color can indicate liver function or jaundice. Choices D, E, and F are not necessarily critical findings to report urgently to the provider in most cases. Monitoring respiratory rate, heart rate, and head assessment findings are important but may not require immediate provider notification unless there are significant abnormalities.
A nurse is caring for a client who is at 20 weeks of gestation and has trichomoniasis. Which of the following findings should the nurse expect?
- A. Thick, white vaginal discharge
- B. Urinary frequency
- C. Vulva lesions
- D. Malodorous discharge
Correct Answer: D
Rationale: The correct answer is D: Malodorous discharge. Trichomoniasis is a sexually transmitted infection caused by a parasite, leading to a characteristic foul-smelling vaginal discharge. This discharge is typically greenish-yellow, frothy, and may be accompanied by itching or irritation. Thick, white discharge (choice A) is more indicative of a yeast infection. Urinary frequency (choice B) is not a common symptom of trichomoniasis. Vulva lesions (choice C) are more likely to be seen in other infections or conditions. Therefore, the malodorous discharge is the most specific finding associated with trichomoniasis at 20 weeks of gestation.
A nurse is caring for a client who is 1 hr postpartum and has uterine atony. The client is exhibiting a large amount of vaginal bleeding. Which of the following actions should the nurse take?
- A. Administer betamethasone IM.
- B. Avoid performing sterile vaginal examinations.
- C. Anticipate a prescription for misoprostol.
- D. Obtain a specimen for a Kleihauer-Betke test.
Correct Answer: C
Rationale: The correct answer is C: Anticipate a prescription for misoprostol. Misoprostol is a medication commonly used to manage postpartum hemorrhage due to uterine atony. It helps to promote uterine contractions and control bleeding. Administering betamethasone (A) is not indicated in this situation as it is a steroid used for fetal lung maturation. Avoiding sterile vaginal examinations (B) may delay the identification of the cause of bleeding. Obtaining a specimen for a Kleihauer-Betke test (D) is used to determine the amount of fetal-maternal hemorrhage and is not the immediate priority in managing uterine atony.