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A postpartum nurse caring for a client who delivered vaginally 2 hours ago palpates the fundus and notes the character of the lochia. Which characteristic of the lochia should indicate to the nurse that the client's recovery is normal?
- A. Pink-colored lochia
- B. White-colored lochia
- C. Serosanguineous lochia
- D. Dark red-colored lochia
Correct Answer: D
Rationale: When checking the perineum, the lochia is monitored for amount, color, and the presence of clots. The color of the lochia during the fourth stage of labor (the first 1 to 4 hours after birth) is dark red. Options 1, 2, and 3 are not the expected characteristics of lochia at this time period.
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The nurse provides information to a preoperative client who will be receiving relaxation therapy. What effects should the nurse teach the client to expect regarding this type of therapy? Select all that apply.
- A. Increased heart rate
- B. Improved well-being
- C. Lowered blood pressure
- D. Increased respiratory rate
- E. Decreased muscle tension
- F. Increased neural impulses to the brain
Correct Answer: B,C,E
Rationale: Relaxation is the state of generalized decreased cognitive, physiological, and/or behavioral arousal. Relaxation elongates the muscle fibers, reduces the neural impulses to the brain, and thus decreases the activity of the brain and other systems. The effects of relaxation therapy include improved well-being; lowered blood pressure, heart rate, and respiratory rate; decreased muscle tension; and reduced symptoms of distress in persons who need to undergo treatments, those experiencing complications from medical treatment or disease, or those grieving the loss of a significant other. This therapy does not cause an increased heart rate, increased respiratory rate, or increased neural impulses to the brain.
A client who experienced a fractured right ankle has a short leg cast applied in the emergency department. During discharge teaching, which information should the nurse provide to the client to prevent complications?
- A. Trim the rough edges of the cast after it is dry.
- B. Weight bearing on the right leg is allowed once the cast feels dry.
- C. Expect burning and tingling sensations under the cast for 3 to 4 days.
- D. Keep the right ankle elevated above the heart level with pillows for 24 hours.
Correct Answer: D
Rationale: Leg elevation is important to increase venous return and decrease edema. Edema can cause compartment syndrome, a major complication of fractures and casting. The client and/or family may be taught how to 'petal' the cast to prevent skin irritation and breakdown, but rough edges, if trimmed, can fall into the cast and cause a break in skin integrity. Weight bearing on a fractured extremity is prescribed by the primary health care provider during follow-up examination, after radiographs are obtained. Additionally, a walking heel or cast shoe may be added to the cast if the client is allowed to bear weight and walk on the affected leg. Although the client may feel heat after the cast is applied, burning and/or tingling sensations indicate nerve damage or ischemia and are not expected. These complaints should be reported immediately.
The nurse performs an assessment on a client newly diagnosed with rheumatoid arthritis. The nurse expects to note which early manifestations of the disease? Select all that apply.
- A. Fatigue
- B. Anorexia
- C. Weakness
- D. Low-grade fever
- E. Joint deformities
- F. Joint inflammation
Correct Answer: A,B,C,D,F
Rationale: Rheumatoid arthritis is a chronic, progressive, systemic inflammatory autoimmune disease process that primarily affects the synovial joints. Early manifestations include fatigue, anorexia, weakness, joint inflammation, low-grade fever, and paresthesia. Joint deformities are late manifestations.
The nurse is scheduling a client for a series of diagnostic studies of the gastrointestinal (GI) system. Which of these studies should the nurse schedule last to avoid altering the results of the remaining tests?
- A. Ultrasound
- B. Colonoscopy
- C. Barium enema
- D. Computed tomography
Correct Answer: C
Rationale: When barium is instilled into the lower GI tract, it may take up to 72 hours to clear the GI tract. The presence of barium could cause interference with obtaining clear visualization and accurate results of the other tests listed if performed before the client has fully excreted the barium. For this reason, diagnostic studies that involve barium contrast are scheduled at the conclusion of other medical imaging studies.
A newborn infant is diagnosed with esophageal atresia. Which assessment finding supports this diagnosis?
- A. Slowed reflexes
- B. Continuous drooling
- C. Diaphragmatic breathing
- D. Passage of large amounts of frothy stool
Correct Answer: B
Rationale: In esophageal atresia, the esophagus terminates before it reaches the stomach, ending in a blind pouch. This condition prevents the passage of swallowed mucus and saliva into the stomach. After fluid has accumulated in the pouch, it flows from the mouth and the infant then drools continuously. Responsiveness of the infant to stimulus would depend on the overall condition of the infant and is not considered a classic sign of esophageal atresia. Diaphragmatic breathing is not associated with this disorder. The inability to swallow amniotic fluid in utero prevents the accumulation of normal meconium, and lack of stools results.