Nokea
A nurse is providing discharge teaching to a client who is postpartum and has an episiotomy. Which of the following statements should the nurse include in the teaching?
- A. Avoid sitting for long periods of time.
- B. Apply a cold pack to the perineal area for the first 24 hours.
- C. Use a sitz bath once per week.
- D. Begin Kegel exercises after the first week.
Correct Answer: B
Rationale: The correct statement to include in the teaching is to apply a cold pack to the perineal area for the first 24 hours. This helps reduce swelling and promote comfort, aiding in the healing process after an episiotomy. Option A is incorrect as it does not provide specific guidance on managing postpartum recovery. Option C is incorrect because using a sitz bath once per week may not be frequent enough for proper wound care. Option D is incorrect because beginning Kegel exercises immediately after delivery can put excessive strain on the perineal area, potentially hindering healing.
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A nurse is preparing to administer Rh immune globulin to a client who is 28 weeks gestation. The nurse should understand that Rh immune globulin is administered to prevent which of the following?
- A. Rh incompatibility
- B. Severe preeclampsia
- C. Placental abruption
- D. Erythroblastosis fetalis
Correct Answer: A
Rationale: The correct answer is A: Rh incompatibility. Rh immune globulin is administered to prevent the formation of antibodies in clients who are Rh-negative and have been exposed to Rh-positive fetal blood. Severe preeclampsia (choice B) is a condition characterized by high blood pressure and signs of damage to organs, not prevented by Rh immune globulin. Placental abruption (choice C) is the separation of the placenta from the uterine wall, not prevented by Rh immune globulin. Erythroblastosis fetalis (choice D) is a condition where maternal antibodies attack fetal red blood cells due to Rh incompatibility, which Rh immune globulin helps prevent.
A client who is 12 weeks pregnant and experiencing nausea and vomiting is receiving teaching from a nurse. Which of the following statements should the nurse include in the teaching?
- A. You should eat foods high in protein before bedtime.
- B. You should avoid consuming liquids with your meals.
- C. You should eat three large meals per day.
- D. You should consume caffeine to help with nausea.
Correct Answer: B
Rationale: The correct answer is B: 'You should avoid consuming liquids with your meals.' This advice is essential because avoiding drinking liquids with meals can help prevent overdistension of the stomach, which can worsen nausea. Option A is incorrect because eating foods high in protein before bedtime may not directly address the issue of nausea and vomiting. Option C is incorrect as eating three large meals a day may exacerbate nausea due to overeating or having an empty stomach for an extended period. Option D is incorrect as consuming caffeine can actually worsen nausea in pregnant clients.
A nurse is teaching a client who is at 20 weeks of gestation about the glucose tolerance test. Which of the following instructions should the nurse include?
- A. You should eat a low-carbohydrate diet for 3 days before the test.
- B. You will need to fast for 12 hours before the test.
- C. You should expect the test to take about 1 hour.
- D. You will need to limit fluid intake to water before the test.
Correct Answer: C
Rationale: The correct answer is C. During a glucose tolerance test, the client is required to drink a glucose solution, and blood samples are taken at specific intervals, typically over a period of 1 to 3 hours. In this case, the nurse should inform the client to expect the test to take about 1 hour. Choices A, B, and D are incorrect because there is no specific instruction to eat a low-carbohydrate diet for 3 days before the test, fast for 12 hours before the test, or limit fluid intake to water before the test in a standard glucose tolerance test.
A nurse is assessing a client who is at 28 weeks of gestation and has gestational hypertension. Which of the following findings should the nurse report to the provider?
- A. 1+ proteinuria
- B. Blood pressure 144/92 mm Hg
- C. Respiratory rate 22/min
- D. Urine output 20 mL/hr
Correct Answer: D
Rationale: The nurse should report a urine output of 20 mL/hr. This finding can indicate decreased renal perfusion and possible development of preeclampsia, which is a severe complication of gestational hypertension. Inadequate urine output can suggest compromised kidney function and impaired maternal and fetal well-being. Options A, B, and C are within normal limits for a client with gestational hypertension and may not require immediate reporting to the provider.
A nurse is caring for a client who is receiving oxytocin for labor induction. Which of the following findings requires immediate intervention?
- A. Contraction frequency of every 3 minutes
- B. Contraction duration of 80 seconds
- C. Late decelerations in the fetal heart rate
- D. Urine output of 50 mL/hr
Correct Answer: C
Rationale: Late decelerations in the fetal heart rate require immediate intervention as they can indicate fetal distress due to uteroplacental insufficiency. This finding suggests a compromised blood flow to the fetus, which can lead to serious complications if not addressed promptly. Contraction frequency and duration are important to monitor but do not necessitate immediate intervention unless they are causing fetal distress. Urine output of 50 mL/hr is within the normal range for a client in labor and does not require immediate intervention.