Nokea
A nurse is assessing a postpartum person for signs of thrombophlebitis. What is the most common sign of thrombophlebitis?
- A. redness and swelling in the calf
- B. pain and swelling in the leg
- C. hardening of the calf
- D. heat intolerance in the leg
Correct Answer: B
Rationale: The correct answer is B: pain and swelling in the leg. Thrombophlebitis is inflammation of a vein due to a blood clot, commonly occurring in the lower extremities. Pain and swelling are classic symptoms due to the clot obstructing blood flow. Redness and heat may be present but are not as specific. Hardening of the calf is not a common sign. Heat intolerance in the leg is not a typical symptom of thrombophlebitis.
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An 18-week gestation client telephones the obstetrician’s office stating, 'I’m really scared. I think I have breast cancer. My breasts are filled with tumors.' The nurse should base the response on which of the following?
- A. Breast cancer is often triggered by pregnancy.
- B. Nodular breast tissue is normal during pregnancy.
- C. The woman is exhibiting signs of a psychotic break.
- D. Anxiety attacks are especially common in the second trimester.
Correct Answer: B
Rationale: Nodular breast tissue is a normal change during pregnancy due to hormonal fluctuations. Breast cancer is not typically triggered by pregnancy, and anxiety attacks are not specifically common in the second trimester.
A couple just learned they are expecting their first child and are curious if they are having a boy or a girl. At what point of development can the couple first expect to see the sex of their child on ultrasound?
- A. 4 weeks’ gestational age
- B. 6 weeks’ gestational age
- C. 10 weeks’ gestational age
- D. 16 weeks’ gestational age
Correct Answer: C
Rationale: The fetal period begins at the ninth week, and by the tenth week the external genitalia are visible to ultrasound examination.
The nurse is caring for a pregnant patient who is at 32 weeks gestation and reports experiencing frequent heartburn. Which of the following interventions is most appropriate for the nurse to recommend?
- A. Lie down immediately after meals to help with digestion.
- B. Eat smaller meals more frequently throughout the day.
- C. Drink large amounts of water after meals to dilute stomach acid.
- D. Avoid eating spicy foods and take antacids regularly.
Correct Answer: B
Rationale: The correct answer is B: Eat smaller meals more frequently throughout the day. This intervention is appropriate because smaller, more frequent meals can help reduce the pressure on the stomach, decrease acid reflux, and alleviate heartburn symptoms in pregnant patients. By eating smaller meals, the pregnant patient can prevent the stomach from becoming overly full and reduce the likelihood of stomach acid regurgitating into the esophagus. This approach promotes better digestion, minimizes discomfort, and supports the overall well-being of the patient and the fetus.
Other choices are incorrect:
A: Lying down immediately after meals can worsen heartburn by allowing stomach acid to flow back into the esophagus.
C: Drinking large amounts of water after meals can further distend the stomach and exacerbate heartburn symptoms.
D: Although avoiding spicy foods and taking antacids may provide temporary relief, they do not address the root cause of the issue and may not be as effective as adopting a dietary change like eating smaller, more frequent meals
The nurse is interviewing a 38-week gestation Muslim woman.
- A. Do you plan to breastfeed your baby?
- B. What do you plan to name the baby?
- C. Which pediatrician do you plan to use?
- D. How do you feel about having an episiotomy?
Correct Answer: D
Rationale: Questions about episiotomy might be culturally sensitive or inappropriate without prior discussion of preferences, especially in certain cultural contexts like Islam.
A pregnant patient at 32 weeks gestation reports difficulty breathing, especially when lying flat. What should the nurse recommend first?
- A. Administer oxygen and prepare the patient for delivery.
- B. Instruct the patient to lie on her left side to reduce pressure on the diaphragm.
- C. Encourage the patient to rest in an upright position and monitor symptoms.
- D. Instruct the patient to take deep breaths and elevate the legs.
Correct Answer: C
Rationale: The correct answer is C because encouraging the patient to rest in an upright position helps improve lung expansion and oxygenation, relieving the difficulty in breathing. By monitoring symptoms, the nurse can assess for any worsening signs or the need for further intervention.
A: Administering oxygen and preparing for delivery is premature without assessing the patient further.
B: Lying on the left side may alleviate pressure on the diaphragm but does not address the underlying cause of difficulty breathing.
D: Instructing to take deep breaths and elevate legs may not be beneficial and could potentially worsen the symptoms.