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A nurse is conducting a discharge teaching for a client going home after cesarean section. Which S&S should the client be taught to report?
- A. Frequency urgency and burning on urination
- B. Feeling pelvic fullness
- C. Redness or edema of abdominal decision
- D. Mild incisional pain
Correct Answer: A
Rationale: After a cesarean section, the client should be taught to report symptoms of a urinary tract infection, such as frequency, urgency, and burning on urination. These symptoms can indicate an infection which needs prompt treatment to prevent complications. It is important for the client to report these symptoms to their healthcare provider for appropriate evaluation and management.
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A nurse is caring for four clients. For which of the following clients should the nurse auscultate the fetal heart rate during the prenatal visit?
- A. A client who has an ultrasound that confirms a molar pregnancy
- B. A client who has a crown-rump length of 7 weeks gestation
- C. A client who has a positive urine pregnancy test 1 week after missed menses
- D. A client who has felt quickening for the first time
Correct Answer: B
Rationale: The nurse should auscultate the fetal heart rate during the prenatal visit for the client who has a crown-rump length of 7 weeks gestation. At this stage, the fetal heart is usually visible on ultrasound, and auscultating the fetal heart rate can provide valuable information about the health and development of the fetus. It is an important part of prenatal care to monitor the fetal heart rate regularly to ensure the well-being of the baby. In the other scenarios provided:
When reviewing the arterial blood gas values for a client, a nurse notes a pH of 7.32, PaCO2 of 48 mm Hg, and HCO3 of 23 mEq/L. What does this indicate about the acid-base balance?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: A
Rationale: The given values suggest respiratory acidosis. In respiratory acidosis, the pH is low (<7.35), PaCO2 is high (>45 mm Hg), and the HCO3 is normal or slightly elevated. In this scenario, the low pH (7.32) and high PaCO2 (48 mm Hg) indicate respiratory acidosis, where there is an excess of carbon dioxide in the blood, leading to acidification of the body fluids.
The nurse assess that a newborn is in respiratory distress when the infant exhibits:
- A. Apnea, grunting, wheezing, and crackles
- B. Wheezing, cyanosis, hiccups, and crackles
- C. Cyanosis, retraction, wheezing, and hiccups
- D. Tachypnea, retraction, grunting, and cyanosis
Correct Answer: D
Rationale: In newborns, respiratory distress can present with various signs and symptoms. The combination of tachypnea (rapid breathing), chest retractions (visible sinking of the skin in between or below the ribs with each breath), grunting (sound made during expiration), and cyanosis (blue discoloration of the skin and mucous membranes) are indicative of respiratory distress in a newborn. These signs suggest that the newborn is having difficulty breathing and may require immediate medical attention. It is essential to recognize and address respiratory distress promptly to ensure the well-being of the newborn.
A woman delivered a baby 9lbs 10oz 1 hour ago. When you
arrive to perform a 15-minute assessment she tells you that she feels
all wet underneath. You discover that both pads are completely
saturated and that she’s lying in a 6-inch diameter of blood. What
does nurse do first
- A. Assess the fundus for firmness
- B. Change the patient's pads
- C. Notify the provider
- D. Document the findings
Correct Answer: A
Rationale: In this scenario, the priority action for the nurse to take is to assess the source of the woman's feeling of wetness underneath her. This could indicate a significant amount of postpartum bleeding, also known as hemorrhage. It is crucial to determine if she is experiencing excessive bleeding as this can be life-threatening if not addressed promptly. By identifying the source of the wetness, the nurse can assess the situation and take appropriate actions to address any potential complications. Once the severity of bleeding is determined, further assessments and interventions can be initiated accordingly.
A client with chronic kidney disease has arterial blood gas values being reviewed by a nurse. Which of the following sets of values should the nurse expect?
- A. pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg
- B. pH 7.30, HCO3- 26 mEq/L, PaCO2 50 mm Hg
- C. pH 7.50, HCO3- 20 mEq/L, PaCO2 32 mm Hg
- D. pH 7.55, HCO3- 30 mEq/L, PaCO2 31 mm Hg
Correct Answer: A
Rationale: In chronic kidney disease, metabolic acidosis is common due to impaired kidney function leading to reduced bicarbonate excretion. The correct values indicating metabolic acidosis in this scenario are a low pH (acidosis), low bicarbonate (HCO3-) level, and low PaCO2 (compensation through respiratory alkalosis). Therefore, the expected values for a client with chronic kidney disease would be pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg, as depicted in choice A.