Nokea
A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in their left calf. Which of the following actions should the nurse take?
- A. Administer aspirin for pain.
- B. Maintain the client on bed rest.
- C. Massage the affected leg every 12 hr.
- D. Apply cold compresses to the affected calf.
Correct Answer: B
Rationale: Maintaining the client on bed rest helps prevent the dislodgement of a thrombus, which could lead to a pulmonary embolism, a life-threatening complication.
You may also like to solve these questions
A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia?
- A. Hypertonia
- B. Increased feeding
- C. Hyperthermia
- D. Respiratory distress
Correct Answer: D
Rationale: The correct answer is D: Respiratory distress. Hypoglycemia in a late preterm newborn can lead to respiratory distress due to inadequate energy supply to respiratory muscles. Hypertonia (choice A) is not a typical manifestation of hypoglycemia. Increased feeding (choice B) is a compensatory mechanism to raise blood glucose levels. Hyperthermia (choice C) is not directly related to hypoglycemia. Therefore, the most appropriate choice indicating hypoglycemia in this scenario is respiratory distress.
A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching?
- A. "I will eat foods that taste good instead of balancing my meals."
- B. "I will avoid having a snack before I go to bed each night."
- C. "I will have a cup of hot tea with each meal."
- D. "I will eliminate products that contain dairy from my diet."
Correct Answer: D
Rationale: The correct answer is D: "I will eliminate products that contain dairy from my diet." This is because hyperemesis gravidarum is a condition characterized by severe nausea and vomiting during pregnancy. Dairy products can be harder to digest and may exacerbate nausea. By eliminating dairy, the client can reduce the likelihood of triggering nausea and vomiting.
A: "I will eat foods that taste good instead of balancing my meals." - This statement does not address the dietary changes needed for hyperemesis gravidarum.
B: "I will avoid having a snack before I go to bed each night." - While avoiding snacks before bedtime can be a good practice for some, it does not specifically address the dietary needs of hyperemesis gravidarum.
C: "I will have a cup of hot tea with each meal." - Hot tea may not necessarily help with managing hyperemesis gravidarum symptoms and does not address the need for dietary modifications.
Which of the following is a potential ethical issue related to fetal surgery?
- A. Informed consent
- B. Allocation of resources
- C. End-of-life decision making
- D. All of the above
Correct Answer: A
Rationale: Informed consent is a key ethical issue in fetal surgery, ensuring parents understand the risks and benefits.
A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take?
- A. Limit the amount of time the fetus is in the client’s room.
- B. Provide the client with photos of the fetus.
- C. Instruct the client that an autopsy should be performed within 24 hr.
- D. Inform the client that the law requires them to name the fetus.
Correct Answer: B
Rationale: The correct answer is B: Provide the client with photos of the fetus. This action allows the client to have tangible memories of their stillborn baby, aiding in the grieving process and facilitating closure. It is important for the client to have something to remember their child by, as it validates the existence of the baby and acknowledges the client's loss. It also promotes a sense of connection and remembrance. Providing photos can be a compassionate gesture that supports the client emotionally during this difficult time.
Choice A is incorrect because limiting the time the fetus is in the room may not consider the client's emotional needs. Choice C is incorrect as it may add unnecessary stress to the client. Choice D is incorrect as there is no legal requirement to name a stillborn fetus.
Which of the following is a potential complication of neonatal hypocalcemia?
- A. Hypoglycemia
- B. Seizures
- C. Respiratory distress syndrome
- D. All of the above
Correct Answer: B
Rationale: Seizures are a potential complication of neonatal hypocalcemia due to the critical role of calcium in nerve and muscle function.