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A nurse is assessing a client who is 1 hr postpartum following a vaginal birth. The nurse notes that the client has excessive vaginal bleeding. Which of the following actions should the nurse take first?
- A. Massage the client's fundus.
- B. Administer oxytocin to the client.
- C. Empty the client’s bladder.
- D. Provide oxygen to the client via nonrebreather face mask.
Correct Answer: A
Rationale: The correct action for the nurse to take first is to massage the client's fundus. This is because excessive vaginal bleeding postpartum could indicate uterine atony, which is a common cause of postpartum hemorrhage. By massaging the fundus, the nurse can help stimulate uterine contractions and reduce bleeding. Administering oxytocin (choice B) may be necessary but massaging the fundus should be done first. Emptying the client's bladder (choice C) can also help, but addressing uterine atony is the priority. Providing oxygen (choice D) is not the immediate action needed for excessive vaginal bleeding.
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A nurse is discussing fertility treatment options with a client and their partner. Which of the following nonpharmacological treatments should the nurse suggest?
- A. Use a lubricant during intercourse.
- B. Drink herbal tea two times daily.
- C. Maintain a healthy weight.
- D. Take daily hot baths.
Correct Answer: C
Rationale: The correct answer is C: Maintain a healthy weight. This is because maintaining a healthy weight is a crucial nonpharmacological factor that can positively impact fertility. Excess weight can disrupt hormonal balance and lead to ovulation issues in women and reduced sperm quality in men. A healthy weight can improve the chances of conception.
A: Using a lubricant during intercourse does not directly impact fertility and is not a recommended nonpharmacological treatment option.
B: Drinking herbal tea may have some health benefits, but there is no scientific evidence to support its effectiveness in improving fertility.
D: Taking hot baths can actually have a negative effect on sperm production in men due to the increased temperature in the genital area.
In summary, maintaining a healthy weight is the most appropriate nonpharmacological treatment option for improving fertility compared to the other choices provided.
A nurse is obtaining a 2-hr postprandial blood glucose from a client. Which of the following actions should the nurse take?
- A. Puncture the finger while still damp with antiseptic solution.
- B. Smear the blood onto the reagent strip.
- C. Hold the finger above the heart prior to puncture.
- D. Select the lateral side of the finger for puncture.
Correct Answer: D
Rationale: The correct answer is D: Select the lateral side of the finger for puncture. This is important because the lateral side has fewer nerve endings, making it less painful for the client. Additionally, it reduces the risk of injury to the nerves and blood vessels located on the other sides of the finger. Puncturing the finger while still damp with antiseptic solution (choice A) can dilute the blood sample and affect accuracy. Smearing the blood onto the reagent strip (choice B) may lead to inaccurate results due to improper application. Holding the finger above the heart prior to puncture (choice C) can increase blood flow and potentially affect the glucose level. Therefore, selecting the lateral side of the finger for puncture is the best practice for obtaining a 2-hr postprandial blood glucose sample.
A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take?
- A. Replace the surgical dressing.
- B. Evaluate urinary output.
- C. Apply an ice pack to the incision site.
- D. Administer 500 mL lactated Ringer’s IV bolus.
Correct Answer: D
Rationale: The correct answer is D: Administer 500 mL lactated Ringer’s IV bolus. This action is necessary to address the persistent vaginal bleeding after cesarean birth, as it could be a sign of postpartum hemorrhage. Administering IV fluids helps to improve circulating volume and maintain adequate perfusion to vital organs. This can help stabilize the client's condition while further assessments and interventions are carried out.
Choice A: Replacing the surgical dressing does not address the underlying cause of the bleeding and is not a priority at this time.
Choice B: Evaluating urinary output is important but not the immediate action needed to address the vaginal bleeding.
Choice C: Applying an ice pack to the incision site is not appropriate for controlling postpartum bleeding.
In summary, administering IV fluids is the priority to address potential postpartum hemorrhage, while the other options do not directly address the urgent issue at hand.
A nurse is assessing a client who is at 6 weeks of gestation and adheres to a vegan diet. Which of the following questions should the nurse ask to assess the client’s dietary intake?
- A. How much protein do you eat in a day?
- B. Are you taking a Vitamin C supplement?
- C. Have you considered eating shellfish?
- D. When was the last time you ate meat?
Correct Answer: A
Rationale: The correct answer is A: "How much protein do you eat in a day?" This question is important because a vegan diet may lack sufficient protein, crucial for fetal development at 6 weeks gestation. Protein is essential for cell growth and repair. Choice B is incorrect as Vitamin C is abundant in plant-based foods. Choice C is incorrect because shellfish are not part of a vegan diet. Choice D is incorrect because consuming meat contradicts a vegan diet.
A nurse is providing discharge teaching to a client following tubal ligation. Which of the following statements by the client indicates an understanding of the teaching?
- A. Premenstrual tension will no longer be present.
- B. My monthly menstrual period will be shorter.
- C. Hormone replacements will be needed following this procedure.
- D. Ovulation will remain the same.
Correct Answer: D
Rationale: The correct answer is D: Ovulation will remain the same. After tubal ligation, the fallopian tubes are blocked to prevent the egg from meeting sperm, but ovulation continues. This answer shows understanding of the procedure's mechanism. A: Premenstrual tension may or may not be affected. B: Menstrual periods are not directly affected. C: Hormone replacements are not routinely needed. In summary, D is correct as it reflects accurate knowledge of tubal ligation outcomes, while the other options are either unrelated or incorrect.