Nokea
A nurse is providing discharge teaching to a client following tubal ligation. Which of the following statements by the client indicates an understanding of the teaching?
- A. Premenstrual tension will no longer be present.
- B. My monthly menstrual period will be shorter.
- C. Hormone replacements will be needed following this procedure.
- D. Ovulation will remain the same.
Correct Answer: D
Rationale: The correct answer is D: Ovulation will remain the same. After tubal ligation, the fallopian tubes are blocked to prevent the egg from meeting sperm, but ovulation continues. This answer shows understanding of the procedure's mechanism. A: Premenstrual tension may or may not be affected. B: Menstrual periods are not directly affected. C: Hormone replacements are not routinely needed. In summary, D is correct as it reflects accurate knowledge of tubal ligation outcomes, while the other options are either unrelated or incorrect.
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The nurse is teaching the client about postpartum depression. The nurse should encourage the client to----------------- and ----------------- to help prevent postpartum depression.
- A. Engage in regular physical activity
- B. Maintain a strong support system
- C. Get adequate rest and sleep
- D. Eat a well-balanced diet
- E. exercise 30 min per day
Correct Answer: B,E
Rationale: The correct answers are B and E. Maintaining a strong support system is crucial in preventing postpartum depression as it provides emotional support. Exercise for 30 minutes per day can help release endorphins, reduce stress, and improve mood. Engaging in regular physical activity (choice A) is beneficial but not as specific as the 30-minute exercise recommendation. Getting adequate rest and sleep (choice C) is important but may not solely prevent postpartum depression. Eating a well-balanced diet (choice D) is essential for overall health but does not directly address the prevention of postpartum depression.
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 child, which can aid in the grieving process and provide closure. Providing photos is a sensitive and compassionate gesture that acknowledges the significance of the loss. It also respects the client's autonomy in choosing how they wish to remember their child.
The other choices are not appropriate in this situation:
A: Limiting the time the fetus is in the room may not consider the emotional needs of the client.
C: Instructing the client about an autopsy may be insensitive and distressing without discussing it first with the client.
D: Informing the client about naming the fetus is not a legal requirement and could add unnecessary pressure during a difficult time.
A nurse is reviewing laboratory findings for a client who is at 20 weeks of gestation. Which of the following findings should the nurse report to the provider?
- A. Hematocrit 37% (37% to 47%)
- B. Creatinine 0.9 mg/dL (0.5 to 1 mg/dL)
- C. WBC count 11,000/mm3 (5,000 to 10,000/mm3)
- D. Fasting blood glucose 180 mg/dL (74 to 106 mg/dL)
Correct Answer: D
Rationale: The correct answer is D: Fasting blood glucose 180 mg/dL (74 to 106 mg/dL). At 20 weeks of gestation, elevated blood glucose levels can indicate gestational diabetes, posing risks for both the mother and fetus. The normal range for fasting blood glucose is 74 to 106 mg/dL, so a value of 180 mg/dL is significantly high. The nurse should report this finding to the provider promptly for further evaluation and management to prevent complications.
A: Hematocrit of 37% is within the normal range for pregnancy.
B: Creatinine level of 0.9 mg/dL falls within the normal range.
C: WBC count of 11,000/mm3 is slightly elevated but can be attributed to the normal physiological changes in pregnancy, such as increased demand on the immune system.
Therefore, choices A, B, and C are not significantly concerning at this stage of gestation compared to the high blood glucose
A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis.
- A. Increased warmth in the extremity
- B. Tachycardia
- C. Leukocytosis
- D. Scant lochia rubra
- E. Decreased extremity edema
Correct Answer:
Rationale: Correct Answer:
Rationale:
- Increased warmth in the extremity: Indicates clot progression or inflammation.
- Tachycardia: Can signify a pulmonary embolism or worsening condition.
- Leukocytosis: Suggests infection or inflammatory response.
- Scant lochia rubra: Not directly related to deep vein thrombosis, more common postpartum.
A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take?
- A. Replace the surgical dressing.
- B. Evaluate urinary output.
- C. Apply an ice pack to the incision site.
- D. Administer 500 mL lactated Ringer’s IV bolus.
Correct Answer: D
Rationale: The correct answer is D: Administer 500 mL lactated Ringer’s IV bolus. This action is necessary to address the persistent vaginal bleeding after cesarean birth, as it could be a sign of postpartum hemorrhage. Administering IV fluids helps to improve circulating volume and maintain adequate perfusion to vital organs. This can help stabilize the client's condition while further assessments and interventions are carried out.
Choice A: Replacing the surgical dressing does not address the underlying cause of the bleeding and is not a priority at this time.
Choice B: Evaluating urinary output is important but not the immediate action needed to address the vaginal bleeding.
Choice C: Applying an ice pack to the incision site is not appropriate for controlling postpartum bleeding.
In summary, administering IV fluids is the priority to address potential postpartum hemorrhage, while the other options do not directly address the urgent issue at hand.