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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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The nurse is monitoring a client in labor who is receiving oxytocin. What finding requires immediate intervention?
- A. Contractions lasting 90 seconds.
- B. Contractions every 2–3 minutes.
- C. Fetal heart rate of 100 beats/minute.
- D. Maternal heart rate of 85 beats/minute.
Correct Answer: C
Rationale: A fetal heart rate of 100 bpm indicates bradycardia, which may signify fetal distress and requires immediate action.
The menstrual phase of the menstrual cycle is characterized by what?
- A. shedding of the endometrial lining
- B. ovulation
- C. fertilization
- D. implantation
Correct Answer: A
Rationale:
A nurse in a woman's health clinic is obtaining a health history from a client. Which of the following findings should the nurse identify as increasing the client's risk for developing pelvic inflammatory disease (PID)?
- A. Recurrent Cystitis
- B. Frequent Alcohol Use
- C. Use of Oral Contraceptives
- D. Chlamydia Infection
Correct Answer: D
Rationale: Chlamydia infection is a significant risk factor for developing pelvic inflammatory disease (PID). PID is commonly caused by untreated or inadequately treated sexually transmitted infections such as chlamydia and gonorrhea. When these infections ascend through the reproductive organs, they can lead to inflammation, scarring, and damage to the reproductive structures, resulting in PID. It is crucial for healthcare providers to identify and treat chlamydia infections promptly to prevent complications like PID. Recurrent cystitis (choice A), frequent alcohol use (choice B), and use of oral contraceptives (choice C) do not directly increase the risk for PID as compared to a sexually transmitted infection like chlamydia.
How should a nurse educate a mother about kangaroo care for her preterm infant?
- A. Encourage frequent visits to the NICU
- B. Educate about skin-to-skin contact benefits
- C. Explain the importance of bonding
- D. Teach the mother about safe handling of the newborn
Correct Answer: B
Rationale: Kangaroo care promotes bonding and regulates temperature for preterm infants.
A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22, PaCO2 68 mm Hg, Base excess -2, PaO2 78 mm Hg, Saturation 80%, Bicarbonate 26 mEq/L
- A. Respiratory acidosis
- B. Metabolic acidosis
- C. Metabolic alkalosis
- D. Respiratory alkalosis
Correct Answer: A
Rationale: The ABG values provided indicate respiratory acidosis. In respiratory acidosis, there is an increase in PaCO2 above the normal range (35-45 mm Hg) leading to a decrease in pH (<7.35). In this case, the pH is 7.22 (below normal) with an elevated PaCO2 of 68 mm Hg. The other values do not suggest metabolic acidosis (which would typically show low bicarbonate levels) or metabolic alkalosis. Therefore, the correct interpretation of the ABGs is respiratory acidosis.