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A client who is postpartum is receiving discharge teaching from a nurse. For which of the following clinical manifestations should the client be instructed to monitor and report to the provider?
- A. Persistent abdominal striae
- B. Temperature 37.8° C (100.2° F)
- C. Unilateral breast pain
- D. Brownish-red discharge on day 5
Correct Answer: C
Rationale: Rationale: Unilateral breast pain in a postpartum client can indicate mastitis, a bacterial infection of the breast tissue. This requires prompt medical attention to prevent complications like abscess formation.
Other Choices:
A: Abdominal striae are normal after pregnancy and don't require immediate intervention.
B: Mild temperature elevation is common postpartum and doesn't necessarily indicate infection.
D: Brownish-red discharge on day 5 is typically normal lochia and not concerning unless foul-smelling or accompanied by fever.
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What is the most appropriate statement for a nurse to make to a client who has recently experienced a perinatal death?
- A. It must be a comfort to know you have another child.
- B. I'm sad for you.
- C. There is usually something wrong with the baby.
- D. You will always have an angel in heaven.
Correct Answer: B
Rationale: The correct answer is B: "I'm sad for you." This response shows empathy and acknowledges the client's feelings without making assumptions or providing false reassurance. It validates the client's emotions and offers support.
Incorrect choices:
A: This statement assumes the client's feelings and may not be comforting.
C: This statement is insensitive and can cause unnecessary guilt or blame.
D: While well-intentioned, this statement may not align with the client's beliefs and can be dismissive of their grief.
A healthcare provider is discussing the differences between true labor and false labor with a group of expectant parents. Which of the following characteristics should the healthcare provider include when discussing true labor?
- A. Contractions become stronger with walking.
- B. Discomfort can be relieved with a back massage.
- C. Contractions become irregular with a change in activity.
- D. Discomfort is felt above the umbilicus.
Correct Answer: A
Rationale: The correct answer is A: Contractions become stronger with walking. This is because true labor is characterized by contractions that consistently increase in intensity and frequency, which is often enhanced by physical activity like walking. Contractions in false labor do not typically intensify with movement. Discomfort in true labor is usually not easily relieved by a back massage (B) and contractions in true labor remain regular even with changes in activity (C). Discomfort in true labor is typically felt in the lower abdomen and back, not above the umbilicus (D).
An adolescent is being taught about levonorgestrel contraception by a school nurse. What information should the nurse include in the teaching?
- A. You should take the medication within 72 hours following unprotected sexual intercourse.
- B. Do not take this medication if you are on an oral contraceptive.
- C. If you do not start your period within 5 days of taking this medication, you will need a pregnancy test.
- D. One dose of this medication will prevent pregnancy for 14 days after taking it.
Correct Answer: A
Rationale: Step 1: Levonorgestrel is a type of emergency contraception that is most effective when taken within 72 hours after unprotected sex.
Step 2: Taking the medication within the specified time frame increases its effectiveness in preventing pregnancy.
Step 3: Thus, the nurse should emphasize to the adolescent the importance of taking the medication promptly after unprotected intercourse.
Step 4: This information is crucial for the adolescent to understand the time-sensitive nature of levonorgestrel contraception.
Summary:
- Choice B is incorrect because it provides contradictory information. Levonorgestrel can be taken even if the individual is on an oral contraceptive.
- Choice C is incorrect as starting a period is not a reliable indicator of pregnancy. A pregnancy test is recommended if there are concerns.
- Choice D is incorrect because levonorgestrel is a single-dose emergency contraception and does not provide protection for 14 days.
A healthcare provider in an antepartum clinic is collecting data from a client who has a TORCH infection. Which of the following findings should the healthcare provider expect? (Select all that apply)
- A. Joint pain
- B. Malaise
- C. Rash
- D. Tender lymph nodes
Correct Answer: D
Rationale: The correct answer is D: Tender lymph nodes. In TORCH infections, which include Toxoplasmosis, Other (syphilis), Rubella, Cytomegalovirus, and Herpes simplex virus, tender lymph nodes are a common finding due to the body's immune response to the infection. Joint pain (choice A) is not typically associated with TORCH infections. Malaise (choice B) is a general feeling of discomfort and is not specific to TORCH infections. Rash (choice C) is also not a common finding in TORCH infections, making it an incorrect choice.
While caring for a newborn undergoing phototherapy to treat hyperbilirubinemia, which of the following actions should the nurse take?
- A. Cover the newborn's eyes with an opaque eye mask while under the phototherapy light.
- B. Keep the newborn in a shirt while under the phototherapy light.
- C. Apply a light moisturizing lotion to the newborn's skin.
- D. Turn and reposition the newborn every 4 hours while undergoing phototherapy.
Correct Answer: A
Rationale: Correct Answer: A - Cover the newborn's eyes with an opaque eye mask while under the phototherapy light.
Rationale:
1. Phototherapy light can cause eye damage, so covering the newborn's eyes with an opaque eye mask protects them.
2. Newborns' eyes are more sensitive to light, making eye protection crucial during phototherapy.
Summary of Incorrect Choices:
B: Keeping the newborn in a shirt won't protect the eyes from phototherapy light.
C: Applying lotion can interfere with the effectiveness of phototherapy and may cause skin irritation.
D: Turning and repositioning the newborn is important for comfort, but eye protection is the priority during phototherapy.