Nokea
A client who had a cesarean delivery 24 hours ago complains of pain from abdominal distention. The client has been on nothing-by-mouth status for the past 36 hours. The nurse should:
- A. Offer the client a carbonated beverage twice daily.
- B. Tell the client to use a straw when drinking fluids.
- C. Limit the client to a soft diet until more bowel sounds exist.
- D. Encourage ambulation in the hallway.
Correct Answer: D
Rationale: Ambulation promotes bowel motility, relieving abdominal distention.
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After circumcision with a Plastibell, the nurse should instruct the neonate's mother to cleanse the circumcision site with which of the following?
- A. Warm water.
- B. Povidone-iodine (Betadine) solution.
- C. Diluted hydrogen peroxide.
Correct Answer: A
Rationale: Warm water is recommended for cleansing the circumcision site to keep it clean and promote healing without causing irritation.
A primiparous client bottle-feeding her neonate asks about sterilizing bottles. The nurse should instruct the client to:
- A. Boil bottles for 10 minutes after each use.
- B. Use a dishwasher with a sanitize cycle.
- C. Soak bottles in bleach solution daily.
- D. Wash bottles with hot soapy water only.
Correct Answer: B
Rationale: A dishwasher with a sanitize cycle effectively sterilizes bottles, ensuring safety for the neonate.
The physician determines that outlet forceps are needed to assist in the delivery of a primigravid client in active labor with a large-for-gestational-size fetus. The nurse reinforces the physician's explanation for using forceps based on the understanding about which of the following concerning the location of the fetus?
- A. Fetal head at the pelvic outlet.
- B. Fetal head at the ischial spines.
- C. Fetal head above the pelvic brim.
- D. Fetal head in the false pelvis.
Correct Answer: A
Rationale: Outlet forceps are used when the fetal head is at the pelvic outlet, visible at the perineum, allowing safe assisted delivery. Higher fetal positions require different interventions.
Two hours after vaginally delivering a viable male neonate under epidural anesthesia, the client with a midline episiotomy ambulates to the bathroom to void. After voiding, the nurse assesses the client's bladder, finding it distended. The nurse interprets this finding based on the understanding that the client's bladder distention is most likely caused by which of the following?
- A. Prolonged first stage of labor.
- B. Urinary tract infection.
- C. Pressure of the uterus on the bladder.
- D. Edema in the lower urinary tract area.
Correct Answer: D
Rationale: Edema in the lower urinary tract, often from delivery trauma or epidural anesthesia, can cause urinary retention and bladder distention.
A primiparous client 3 days postpartum is to be discharged on heparin therapy. After teaching her about possible adverse effects of heparin therapy, the nurse determines that the client needs further instruction when she states the adverse effects include which of the following?
- A. Epistaxis.
- B. Bleeding gums.
- C. Slow pulse.
- D. Petechiae.
Correct Answer: C
Rationale: Slow pulse is not a typical adverse effect of heparin; bleeding symptoms like epistaxis, bleeding gums, and petechiae are expected.