Nokea
A nurse is providing discharge instructions to a client following a cesarean birth. Which of the following should the nurse include in the instructions?
- A. Limit stair climbing for the first few weeks
- B. Avoid lifting anything heavier than the newborn
- C. Use a pillow to support the abdomen when coughing or sneezing
- D. All of the above
Correct Answer: D
Rationale: After a cesarean birth, the client should limit physical activity, including stair climbing and lifting, to allow the incision to heal. Supporting the abdomen with a pillow when coughing or sneezing can also reduce discomfort and protect the incision.
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A nurse on a postpartum unit is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?
- A. A client who gave birth 1 day ago and needs Rho(D) immune globulin
- B. A client who gave birth 3 days ago and reports breast fullness
- C. A client who gave birth 12 hr ago and reports an increase in urinary output
- D. A client who gave birth 8 hr ago and is saturating a perineal pad every hour
Correct Answer: D
Rationale: The client saturating a perineal pad every hour may be experiencing postpartum hemorrhage, which is a medical emergency requiring immediate assessment and intervention.
A nurse is assessing a newborn who is 10 hr old. Which of the following findings should the nurse report to the provider?
- A. Axillary temperature 36.5° C (97.7° F)
- B. Nasal flaring
- C. Heart rate 158/min
- D. One void since birth
Correct Answer: B
Rationale: Nasal flaring can indicate respiratory distress and should be reported immediately for further evaluation.
Following delivery, the nurse places the newborn under a radiant heat warmer. Which of the following is this action used to prevent?
- A. Cold stress
- B. Hyperthermia
- C. Dehydration
- D. Hypoxia
Correct Answer: A
Rationale: Cold stress in newborns can lead to increased oxygen consumption and energy expenditure as the body tries to maintain its temperature. This can result in hypoglycemia and metabolic acidosis if not addressed. The use of a radiant warmer helps maintain the infant's body temperature, reducing the risk of cold stress and its complications.
A nurse is conducting an infertility assessment for a newly admitted client. Which of the following factors should the nurse identify as affecting the client's fertility?
- A. Premature ovarian failure
- B. Renal calculi
- C. Dysmenorrhea
- D. Recurrent urinary tract infection
Correct Answer: A
Rationale: Premature ovarian failure affects fertility by leading to reduced or absent ovarian function, resulting in decreased estrogen production and irregular menstrual cycles.
A nurse is providing education to a client in the first trimester of pregnancy. What information should the nurse include regarding the cause of indigestion and heartburn?
- A. Estrogen causes increased appetite
- B. Progesterone causes relaxation of the cardiac sphincter allowing acid to reflux
- C. HCG hormone leads to increased gastric acidity
- D. The uterus compresses the stomach early in pregnancy
Correct Answer: B
Rationale: Progesterone causes relaxation of the smooth muscles in the body, including the cardiac sphincter. This allows stomach acid to reflux into the esophagus, causing heartburn, especially during pregnancy.