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A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis.
- A. Increased warmth in the extremity
- B. Tachycardia
- C. Leukocytosis
- D. Scant lochia rubra
- E. Decreased extremity edema
Correct Answer:
Rationale: Correct Answer:
Rationale:
- Increased warmth in the extremity: Indicates clot progression or inflammation.
- Tachycardia: Can signify a pulmonary embolism or worsening condition.
- Leukocytosis: Suggests infection or inflammatory response.
- Scant lochia rubra: Not directly related to deep vein thrombosis, more common postpartum.
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A nurse is caring for a client who is at 20 weeks of gestation and has trichomoniasis. Which of the following findings should the nurse expect?
- A. Thick, white vaginal discharge
- B. Urinary frequency
- C. Vulva lesions
- D. Malodorous discharge
Correct Answer: D
Rationale: The correct answer is D: Malodorous discharge. Trichomoniasis is a sexually transmitted infection caused by a parasite, leading to a foul-smelling vaginal discharge. At 20 weeks of gestation, the nurse should expect this symptom due to the infection. Thick, white vaginal discharge (choice A) is more indicative of a yeast infection. Urinary frequency (choice B) is not typically associated with trichomoniasis. Vulva lesions (choice C) are more commonly seen in herpes infection. Therefore, the malodorous discharge (choice D) aligns with the expected finding in a client with trichomoniasis at 20 weeks of gestation.
A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Monitor blood glucose level every hr.
- B. Place the infant on his back with legs extended.
- C. Initiate seizure precautions.
- D. Provide a stimulating environment.
Correct Answer: C
Rationale: The correct answer is C: Initiate seizure precautions. Neonatal abstinence syndrome can lead to seizures due to drug withdrawal. Seizure precautions involve ensuring a safe environment, padded crib, monitoring vital signs closely, and having emergency medications and equipment readily available. Monitoring blood glucose every hour (A) is not typically necessary for neonatal abstinence syndrome. Placing the infant on their back with legs extended (B) is a basic positioning technique and not specific to addressing the syndrome. Providing a stimulating environment (D) would be inappropriate and could exacerbate symptoms.
The nurse is assessing the client 30 min later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication of potential improvement, or an indication of potential worsening condition.
- A. Fundus at level of umbilicus
- B. Cloudy urine
- C. Blood pressure 80/50 mm Hg
- D. Moderate lochia rubra
- E. Thready pulse
- F. Fundus firm to palpation
Correct Answer:
Rationale: Correct Answer:
Rationale:
- Fundus at the level of the umbilicus indicates proper involution of the uterus, a sign of potential improvement.
- Cloudy urine is unrelated to the diagnosis and may indicate a urinary tract infection.
- Blood pressure of 80/50 mm Hg is an indication of potential worsening condition, indicating hypotension.
- Moderate lochia rubra is a normal finding in the postpartum period.
- Thready pulse is an indication of potential worsening condition, suggesting poor perfusion.
- Fundus firm to palpation is a normal finding indicating proper uterine contraction and involution.
A nurse is providing prenatal teaching to a client who practices a vegan diet and is trying to increase intake of vitamin B12. Which of the following foods should the nurse recommend?
- A. Fortified soy milk
- B. Raw carrots
- C. Fresh citrus fruits
- D. Brown rice
Correct Answer: A
Rationale: The correct answer is A: Fortified soy milk. Soy milk is often fortified with vitamin B12, making it a suitable option for a client following a vegan diet. Vitamin B12 is primarily found in animal products, so vegans need to ensure they get an adequate intake from fortified foods or supplements. Raw carrots (B), fresh citrus fruits (C), and brown rice (D) do not contain significant amounts of vitamin B12 and would not be effective in increasing intake. A detailed explanation is crucial in guiding the client to make informed choices for their dietary needs.
A nurse is assessing a client who is 6 hr postpartum and has endometritis. Which of the following findings should the nurse expect?
- A. Temperature 37.4°C (99.3°F)
- B. WBC count 9,000/mm3
- C. Uterine tenderness
- D. Scant lochia
Correct Answer: C
Rationale: The correct answer is C: Uterine tenderness. Endometritis is an infection of the uterine lining that can occur postpartum. Uterine tenderness is a common finding in clients with endometritis due to inflammation and infection. A: A temperature of 37.4°C (99.3°F) is within normal range and may not specifically indicate endometritis. B: A WBC count of 9,000/mm3 is also within normal limits and may not be specific to endometritis. D: Scant lochia may be seen in clients with endometritis, but it is not a defining characteristic.