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A nurse is collecting data from a client who is at 30 weeks of gestation. Which of the following findings should the nurse identify as a manifestation of pyelonephritis?
- A. Epigastric discomfort
- B. Flank pain
- C. Temperature 37.7°C (99.8°F)
- D. Abdominal cramping
Correct Answer: B
Rationale: The correct answer is B: Flank pain. Pyelonephritis is a kidney infection commonly characterized by flank pain, which is a key symptom. Flank pain is typically located on the side of the body between the upper abdomen and the back. This pain occurs due to inflammation of the kidney tissues. The other choices are incorrect because: A) Epigastric discomfort is more indicative of issues related to the upper abdomen, such as gastritis or pancreatitis. C) A temperature of 37.7°C (99.8°F) is slightly elevated but not specific to pyelonephritis. D) Abdominal cramping is more suggestive of gastrointestinal issues like gas or constipation. Therefore, the presence of flank pain is the most relevant finding to identify pyelonephritis in a client at 30 weeks of gestation.
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A nurse is preparing to perform Leopold maneuvers on a client who is at 36 weeks of gestation. Identify the sequence of actions the nurse should take.
- A. Instruct the client to empty their bladder.
- B. Position the client supine with knees flexed and place a small, rolled towel under one of their hips.
- C. Palpate the fetal part positioned in the fundus.
- D. Palpate the fetal parts along both sides of the uterus.
Correct Answer: A, B, C, D
Rationale: The correct order for performing Leopold maneuvers on a client at 36 weeks gestation is A, B, C, D. Firstly, instructing the client to empty their bladder (A) allows for better visualization and palpation of the fetus. Secondly, positioning the client supine with knees flexed and placing a small, rolled towel under one hip (B) helps relax the abdominal muscles and provides easier access to the uterus. Next, palpating the fetal part positioned in the fundus (C) helps determine the fetal presentation and position. Finally, palpating the fetal parts along both sides of the uterus (D) allows for further assessment of the fetal position and presentation. Choices E, F, and G are incorrect as they do not align with the sequential steps required for conducting Leopold maneuvers effectively.
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 instructions to a client who is breastfeeding her newborn. Which of the following instructions should the nurse include?
- A. Feed the newborn 5 to 10 min per breast.
- B. Offer the newborn 30 mL (1 oz) of water between feedings.
- C. Expect two to four wet diapers every 24 hr.
- D. Allow the baby to feed at least every 3 hr.
Correct Answer: D
Rationale: The correct answer is D: Allow the baby to feed at least every 3 hr. This instruction is essential to ensure the newborn receives adequate nutrition and maintains a healthy breastfeeding schedule. Feeding every 3 hours helps in establishing a proper feeding routine, ensures the baby gets enough milk, stimulates milk production in the mother, and helps prevent issues like engorgement and mastitis.
Choice A is incorrect because feeding time should not be restricted to a specific duration. Choice B is incorrect as water is unnecessary for newborns who are exclusively breastfed. Choice C is incorrect as the number of wet diapers can vary and is not a reliable indicator of sufficient milk intake. Choices E, F, and G are not provided.
A nurse is assessing a newborn whose mother had gestational diabetes mellitus. The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?
- A. Abdominal distention
- B. Petechiae
- C. Increased muscle tone
- D. Jitteriness
Correct Answer: D
Rationale: The correct answer is D: Jitteriness. Neonates born to mothers with gestational diabetes are at risk for hypoglycemia due to the abrupt cessation of the maternal glucose supply postnatally. Jitteriness is a common manifestation of hypoglycemia in newborns. It is important for the nurse to monitor for this sign as it indicates the need for prompt intervention to prevent further complications. Abdominal distention, petechiae, and increased muscle tone are not typically associated with hypoglycemia in newborns born to mothers with gestational diabetes.
A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception. Which of the following instructions should the nurse include?
- A. You should have your provider refit you for a new diaphragm.'
- B. You should use an oil-based vaginal lubricant when inserting your diaphragm.'
- C. You should keep the diaphragm in place for at least 4 hours after intercourse.'
- D. You should store your diaphragm in sterile water after each use.'
Correct Answer: A
Rationale: Correct Answer: A. The nurse should instruct the client to have her provider refit her for a new diaphragm because the body undergoes changes postpartum, affecting the size and shape of the cervix and vaginal canal. A new fitting ensures proper size and fit for effective contraception.
B: Using oil-based vaginal lubricant can damage the diaphragm and increase the risk of breakage.
C: Keeping the diaphragm in place for a prolonged period increases the risk of toxic shock syndrome and infection, so it should be removed within 24 hours.
D: Storing the diaphragm in sterile water can lead to bacterial growth, increasing the risk of infection. It should be stored in a dry, cool place.