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A client, who is 6 hours post–vaginal delivery, has a BP of 150/110. Her last 4 BP readings were: 114/88, 120/80, 134/86, 140/90. Which of the following questions should the nurse ask the client at this time?
- A. Have you had a bowel movement since delivery?'
- B. Is there anything that is making you anxious about the baby?'
- C. When you last went to the bathroom were you bleeding heavily?'
- D. Do you have a headache or blurring of your vision?'
Correct Answer: D
Rationale: Headache or blurring of vision could indicate postpartum preeclampsia, a serious condition requiring immediate intervention.
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The nurse is performing the interval history on a patient at 30 weeks of gestation. What data would the prenatal nurse bring to the attention of the health-care provider?
- A. Hgb change from 12 g/dL (at first prenatal visit) to 11 g at 28 weeks
- B. negative ketones in the urine
- C. dysuria for 3 days
- D. weight gain of 3 pounds in the last 2 weeks
Correct Answer: C
Rationale: Rationale: Choice C (dysuria for 3 days) is the correct answer as it could indicate a urinary tract infection (UTI) which can lead to complications during pregnancy. Dysuria may be a sign of UTI, which can progress quickly in pregnant women. Bringing this to the health-care provider's attention is essential for prompt treatment to prevent potential harm to both the mother and baby.
Summary of other choices:
A: Hgb change is within normal range for pregnancy, not necessarily alarming.
B: Negative ketones in the urine are expected and indicate adequate glucose utilization.
D: Weight gain of 3 pounds in 2 weeks is considered normal in the third trimester and not typically a cause for concern unless sudden or excessive.
The nurse is teaching a patient at 28 weeks of gestation how to perform fetal movement counts. What statement by the patient indicates the patient understands teaching?
- A. I need to count the baby's movements for 1 hour every day.
- B. I should wait to count the baby's movements after work.
- C. If the baby moves less than 10 times in 2 hours, I need to call the midwife.
- D. Once the baby moves 5 times, I can stop counting the movements.
Correct Answer: C
Rationale: The correct answer is C because it accurately reflects the recommended protocol for fetal movement counts. By counting fetal movements over a 2-hour period and contacting the midwife if fewer than 10 movements are felt, the patient demonstrates understanding of the importance of monitoring fetal well-being. This approach aligns with the standard practice of assessing fetal activity as a crucial indicator of fetal health.
Choice A is incorrect because counting for 1 hour may not provide a comprehensive assessment. Choice B is incorrect as it suggests delaying monitoring, which could be dangerous if there are concerns about fetal movement. Choice D is incorrect as it implies stopping the count prematurely, potentially missing crucial information about the baby's activity level.
A client complaining of frequency, urgency, and burning on urination is seen by her health care practitioner. Which of the following factors in the client's history places her at risk for these complaints?
- A. The client urinates immediately after every sexual encounter.
- B. The client uses the diaphragm as a family planning method.
- C. The client wipes from front to back after every toileting.
- D. The client changes her peripads every two hours during her menses.
Correct Answer: B
Rationale: The use of a diaphragm can increase the risk of urinary tract infections due to pressure on the urethra.
Which laboratory is important to know when a client is having an amniocentesis?
- A. Blood type
- B. CBC
- C. Rh
- D. PT and PTT
Correct Answer: C
Rationale: Step-by-step rationale:
1. Rh factor is crucial to know to prevent Rh incompatibility issues during pregnancy.
2. Amniocentesis can pose a risk for Rh sensitization in Rh-negative mothers.
3. Knowing the Rh status helps determine if Rhogam (anti-D) is needed after amniocentesis.
4. Blood type (A) and CBC (B) are important but not directly relevant to amniocentesis.
5. PT and PTT (D) are coagulation tests, typically not required for routine amniocentesis.
The nurse is counseling a woman who has been diagnosed with mild osteoporosis. Which of the following should be included in the counseling session?
- A. Begin a regimen of walking each day.
- B. Refrain from drinking chocolate milk.
- C. Increase her daily intake of red meat.
- D. Only wear shoes with rubber soles.
Correct Answer: A
Rationale: Weight-bearing exercises like walking can help strengthen bones and reduce the risk of fractures in individuals with osteoporosis.