Nokea
A client delivered two days ago and is suspected of having postpartum 'blues.' Which symptoms confirm the diagnosis?
- A. Uncontrollable crying and insecurity
- B. Depression and suicidal thoughts
- C. Sense of the inability to care for the family and extreme anxiety
- D. Nausea and vomiting
Correct Answer: A
Rationale: The correct answer is A because uncontrollable crying and insecurity are classic symptoms of postpartum blues, also known as baby blues. This condition is characterized by mood swings, tearfulness, and feelings of vulnerability. Choices B, C, and D are incorrect as they suggest more severe symptoms associated with postpartum depression or other mental health disorders, which require immediate intervention. Nausea and vomiting (choice D) are not typically associated with postpartum blues. It is essential to differentiate between postpartum blues and more serious conditions to provide appropriate support and treatment to the client.
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A nurse is providing client/patient education to the mother of an 8-year-old child diagnosed with B-hemolytic streptococci infection (strep throat). The nurse emphasizes the importance of promptly starting and completing the entire course of antibiotics.
- A. alleviate painful swallowing to avoid complications of dehydration and malnutrition'
- B. prevent sinusitis or abscess formation on the pharyngeal or peri tonsillar areas'
- C. reduce the risk of anterior cervical lymphadenopathy'
- D. eliminate organisms that might initiate acute renal failure or rheumatic fever'
Correct Answer: D
Rationale: The correct answer is D. Completing the entire course of antibiotics for strep throat is crucial to eliminate the bacteria completely. Failure to do so may lead to potential complications like acute renal failure or rheumatic fever, which are serious systemic conditions associated with untreated strep infections. This is because streptococcal infections can trigger an immune response that can attack other parts of the body if not fully eradicated.
Choice A is incorrect because while completing the antibiotics may alleviate painful swallowing, the main emphasis should be on preventing systemic complications. Choice B is incorrect as sinusitis or abscess formation are not the primary concerns with strep throat. Choice C is incorrect as reducing anterior cervical lymphadenopathy is not the primary goal of antibiotic treatment for strep throat.
In summary, completing the full course of antibiotics is crucial to eliminate the bacteria and prevent serious complications such as acute renal failure or rheumatic fever.
For a client in the second trimester of pregnancy, which assessment data support a diagnosis of pregnancy-induced hypertension (PIH)?
- A. Hemoglobin 10.2 mg/dL and uterine tenderness
- B. Polyuria and weight loss of 3 pounds in the last month
- C. Blood pressure 168/110 and 3+ proteinuria
- D. Hematuria and blood glucose of 160 mg/dL
Correct Answer: C
Rationale: The correct answer is C: Blood pressure 168/110 and 3+ proteinuria. Pregnancy-induced hypertension (PIH) is characterized by high blood pressure (systolic ≥140 mmHg and/or diastolic ≥90 mmHg) and proteinuria. In this case, the blood pressure reading of 168/110 indicates hypertension, and 3+ proteinuria indicates significant protein in the urine, both of which are key diagnostic criteria for PIH.
A: Hemoglobin 10.2 mg/dL and uterine tenderness - These are not specific indicators of PIH.
B: Polyuria and weight loss of 3 pounds in the last month - These symptoms are not typically associated with PIH.
D: Hematuria and blood glucose of 160 mg/dL - Hematuria suggests blood in the urine, which is not a typical finding in PIH, and elevated blood glucose is more indicative of diabetes rather than PIH.
Therefore,
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.
The physician performs an amniotomy for a woman in labor. Which nursing action should follow the procedure?
- A. Check the client's capillary refill and oxygenation.
- B. Monitor the maternal pulse and blood pressure.
- C. Inspect the perineum for lacerations, bleeding, and hematoma.
- D. Assess the fluid for color, odor, and amount.
Correct Answer: D
Rationale: The correct answer is D: Assess the fluid for color, odor, and amount. After an amniotomy, it is important to assess the amniotic fluid to ensure it is clear, odorless, and of the appropriate amount, as changes in these characteristics may indicate fetal distress or infection. Checking capillary refill and oxygenation (Choice A) is not directly related to an amniotomy. Monitoring maternal pulse and blood pressure (Choice B) is important but not the immediate priority post-amniotomy. Inspecting the perineum for lacerations, bleeding, and hematoma (Choice C) is important for overall assessment but not specific to the procedure.
A new mother is crying in her room. She tells the nurse that her new baby boy has enlarged breasts and she thinks that there is something wrong. How should the nurse respond?
- A. Enlarged breasts are common for both boys and girls. It will go away.
- B. Let me look at the baby for you.
- C. Everything is going to be just fine. Your baby is healthy.
- D. You should ask your doctor about that.
Correct Answer: A
Rationale: The correct answer is A. Enlarged breasts in newborn boys and girls are a common physiological phenomenon called breast engorgement due to maternal hormones. The nurse should reassure the mother that it is normal and will resolve on its own. Choice B is unnecessary as the nurse already knows the cause. Choice C is vague and does not address the mother's concern directly. Choice D is not ideal as the nurse can provide basic information on the issue.