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A client in the first trimester reports nausea. What dietary recommendation should the nurse make?
- A. Eat dry crackers before getting out of bed.
- B. Avoid eating throughout the day.
- C. Increase intake of spicy foods.
- D. Consume large, infrequent meals.
Correct Answer: A
Rationale: Dry crackers before rising can help manage nausea by stabilizing blood sugar and reducing gastric discomfort.
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The nurse is teaching a client about signs of labor. Which symptom indicates true labor?
- A. Irregular contractions that stop with activity.
- B. Contractions felt in the abdomen only.
- C. Cervical dilation and effacement.
- D. Absence of fetal movement.
Correct Answer: C
Rationale: True labor is characterized by regular contractions that cause cervical dilation and effacement.
How would a patient who has taken Lamaze education respond when the health-care provider recommends breaking the bag of waters in early labor?
- A. As long as it will speed up my labor, that is fine.â€
- B. I trust whatever intervention you think is right.â€
- C. What are the risks and benefits of breaking my water right now?â€
- D. Will I be able to get an epidural after you break my water?â€
Correct Answer: C
Rationale: Lamaze encourages informed decision-making, prompting patients to ask about risks and benefits.
A nurse is planning to teach a group of clients who are about breastfeeding after returning to work. Which of the following infection should the nurse include in the teaching?
- A. "Thawed breast milk can be refrigerated for up to 72 hours."
- B. "Breast milk can be stored in a deep freezer for 12 months."
- C. Breast milk can be stored at room temperature for up to 12 hours."
- D. "Thawed breast milk that is unused can be refrozen."
Correct Answer: D
Rationale: The correct information for breastfeeding after returning to work is that thawed breast milk that is unused should not be refrozen. Once breast milk has been thawed, it should be used within 24 hours and should not be refrozen. This is important to prevent contamination and maintain the quality of the breast milk for the baby. The other statements provided in the options are correct guidelines regarding the storage of breast milk. Thawed breast milk can be refrigerated for up to 24 hours, breast milk can be stored in a deep freezer for up to 12 months, and breast milk can be stored at room temperature for up to 4 hours.
The nurse is caring for a client in labor who reports intense pressure and the urge to push. What is the priority nursing action?
- A. Perform a sterile vaginal examination.
- B. Instruct the client to breathe through the urge to push.
- C. Notify the healthcare provider.
- D. Increase the oxytocin infusion rate.
Correct Answer: A
Rationale: A vaginal examination is needed to confirm full cervical dilation and readiness for delivery.
A nurse is preparing to administer methylergonovine 0.2 mg orally to a client who is 2 hr. postpartum and has a boggy uterus. For which of the following assessment findings should the nurse withhold the medication?
- A. Blood pressure 142/92 mm Hg
- B. Urine output 100 mL in hr.
- C. Pulse 58/min
- D. Respiratory rate 14/min
Correct Answer: A
Rationale: Methylergonovine is a medication used to help contract the uterus and control postpartum hemorrhage. One of its side effects is vasoconstriction, which can lead to increased blood pressure. The client's blood pressure of 142/92 mm Hg is elevated, and administering methylergonovine could further increase the blood pressure, potentially causing harm to the client. It is important to withhold the medication in this situation to prevent worsening of hypertension. The other assessment findings are within normal ranges and do not contraindicate the administration of methylergonovine.