Nokea
A client who is 12 hours postpartum has a fundus located two fingerbreadths above the umbilicus, deviated to the right of the midline, and less firm than previously noted. Which of the following actions should the nurse take?
- A. Place the client in a side-lying position.
- B. Assist the client to the bathroom to void.
- C. Obtain a prescription for IV oxytocin.
- D. Administer methylergonovine.
Correct Answer: B
Rationale: The correct answer is B: Assist the client to the bathroom to void. This action can help promote uterine contractions by relieving bladder distention, which can cause the fundus to be displaced. Voiding can help the uterus return to its normal position and firmness. Placing the client in a side-lying position (A) may be helpful for fundal massage but addressing bladder distention is the priority. Obtaining a prescription for IV oxytocin (C) or administering methylergonovine (D) are not indicated as first-line interventions for a fundus located above the umbilicus postpartum.
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When reviewing postpartum nutrition needs with breastfeeding clients, which statement indicates an understanding of the teaching?
- A. I am glad I can have my morning coffee.
- B. I should take folic acid to increase my milk supply.
- C. I will continue adding 330 calories per day to my diet.
- D. I will continue my calcium supplements because I don't like milk.
Correct Answer: D
Rationale: The correct answer is D because it demonstrates an understanding of the importance of calcium intake for breastfeeding mothers. Calcium is essential for both the mother's health and the baby's bone development. Continuing calcium supplements shows a commitment to meeting nutritional needs.
Incorrect choices:
A: Having coffee is fine, but it's not directly related to postpartum nutrition needs.
B: Folic acid is important for pregnancy but not specifically for increasing milk supply.
C: While additional calories are needed during breastfeeding, the specific amount varies and is not always 330 calories per day.
When discussing intermittent fetal heart monitoring with a newly licensed nurse, which statement should a nurse include?
- A. Count the fetal heart rate for 15 seconds to determine the baseline.
- B. Auscultate the fetal heart rate every 5 minutes during the active phase of the first stage of labor.
- C. Count the fetal heart rate after a contraction to determine baseline changes.
- D. Auscultate the fetal heart rate every 30 minutes during the second stage of labor.
Correct Answer: C
Rationale: The correct answer is C because counting the fetal heart rate after a contraction helps determine baseline changes, which is essential for identifying fetal distress. This method allows for accurate assessment of fetal well-being in response to contractions. Choice A is incorrect as 15 seconds is not enough time to establish a baseline. Choice B is incorrect as auscultating every 5 minutes may not provide timely information during the active phase. Choice D is incorrect because auscultating every 30 minutes in the second stage may miss important changes in fetal status. Therefore, option C is the most appropriate choice for intermittent fetal heart monitoring.
A nurse in a health clinic is reinforcing teaching about contraceptive use with a group of clients. Which of the following client statements demonstrates understanding?
- A. Using a water-soluble lubricant with condoms can help prevent breakage and ensure effectiveness in preventing pregnancy and STIs.
- B. A diaphragm should be removed 2 hours after intercourse.
- C. Oral contraceptives can worsen a case of acne.
- D. A contraceptive patch is replaced once a month.
Correct Answer: A
Rationale: The correct answer is A because using a water-soluble lubricant with condoms can indeed help prevent breakage and maintain effectiveness in preventing pregnancy and STIs. Water-based lubricants are safe to use with condoms as they do not weaken the latex.
Option B is incorrect as a diaphragm should be left in place for at least 6 hours after intercourse, not removed after 2 hours. Option C is also incorrect as oral contraceptives are known to improve acne in many cases. Option D is incorrect as a contraceptive patch is typically replaced weekly, not monthly.
A client is being educated by a healthcare provider about the physiological changes that occur during pregnancy. The client is at 10 weeks of gestation and has a BMI within the expected reference range. Which of the following client statements indicates an understanding of the teaching?
- A. I should gain more than 15 to 20 pounds during my pregnancy.
- B. I will likely need to use alternative positions for sexual intercourse.
- C. I'm glad I had a breast reduction years ago so they will not enlarge with my pregnancy.
- D. I'm glad I have a light complexion and will not get any stretch marks.
Correct Answer: B
Rationale: The correct answer is B: "I will likely need to use alternative positions for sexual intercourse." At 10 weeks of gestation, the uterus begins to enlarge, potentially causing discomfort in the missionary position. This statement shows an understanding of the physical changes in pregnancy.
A is incorrect because the recommended weight gain for a client with normal BMI is 25-35 pounds during pregnancy, not less than 15-20 pounds. C is incorrect as breast size typically increases during pregnancy due to hormonal changes, regardless of prior breast reduction surgery. D is incorrect because stretch marks are common during pregnancy, regardless of skin complexion.
A healthcare professional is preparing to administer magnesium sulfate 2 g/hr IV to a client who is in preterm labor. Available is 20 g of magnesium sulfate in 500 mL of dextrose 5% in water (D5W). How many mL/hr should the IV infusion pump be set to administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 60
- B. 30
- C. 50
- D. 80
Correct Answer: C
Rationale: To calculate the mL/hr for the IV infusion pump, we need to use the formula: (Desired dose in mg/hr * Volume of solution in mL) / Concentration of solution in mg/mL.
Given:
Desired dose = 2 g/hr = 2000 mg/hr
Volume of solution = 500 mL
Concentration of solution = 20 g in 500 mL = 20,000 mg in 500 mL = 40 mg/mL
Now, plug these values into the formula:
(2000 mg/hr * 500 mL) / 40 mg/mL = 25,000 mL/hr
Round this to the nearest whole number, which is 25,000 mL/hr ≈ 50 mL/hr. Therefore, the IV infusion pump should be set to administer 50 mL/hr, making choice C the correct answer.
Option A (60 mL/hr) and Option D (80 mL/hr) are incorrect as they do not match the calculated value. Option