Nokea
A nurse is providing teaching about expected changes during pregnancy to a client who is at 24 weeks of gestation. Which of the following information should the nurse include?
- A. "Your stomach will empty rapidly"
- B. "You should expect your uterus to double in size"
- C. "You should anticipate nasal stuffiness."
- D. "Your nipples will become lighter in color".
Correct Answer: B
Rationale: Option B, "You should expect your uterus to double in size," is the correct information to include when discussing expected changes during pregnancy at 24 weeks of gestation. By this time, the uterus has significantly expanded to accommodate the growing fetus, which is the most notable physical change during pregnancy. It is essential for the client to understand the normal physiological changes that occur during pregnancy to ensure they are informed and prepared for the expected progression of their pregnancy.
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Alexander was an actor who developed a medical technique. What was the basis for this technique?
- A. Relaxing his throat helped his voice return to normal.
- B. Relaxing his back helped him overcome chronic back pain.
- C. Sitting upright allowed him to breathe better.
- D. Better posture controlled his movements.
Correct Answer: A
Rationale: The Alexander Technique originated from F.M. Alexander's efforts to relax his throat and restore his voice.
What is the second stage of pathophysiology in an on anticoagulant therapy due to a deep vein throm- amniotic fluid embolism characterized by? bosis, which occurred after giving birth. Which of
- A. Hemorrhage the following instructions should the nurse include?
- B. Hypoxia
- C. Take an herbal supplement such as St. John's wort
- D. Capillary damage to help increase the effect of the anticoagulant.
Correct Answer: A
Rationale: The second stage of pathophysiology in an amniotic fluid embolism characterized by deep vein thrombosis on anticoagulant therapy after giving birth involves the risk of hemorrhage. Anticoagulant therapies such as heparin increase the risk of bleeding since they inhibit the blood's ability to clot effectively. This means that in the event of an injury or surgery, there is a higher likelihood of excessive bleeding. Therefore, it is crucial to monitor for signs of hemorrhage such as bruising, bleeding gums, blood in urine or stool, and low blood pressure. Intervention to manage bleeding may include reducing the dosage of the anticoagulant, administering blood products, and implementing pressure or surgical interventions as necessary.
The nurse is performing an assessment of a postpartum client. Which finding requires immediate action?
- A. Temperature of 100.4°F.
- B. Foul-smelling lochia.
- C. Fundus firm and midline.
- D. Breast tenderness on palpation.
Correct Answer: B
Rationale: Foul-smelling lochia may indicate an infection and requires prompt medical evaluation.
After her baby's birth a patient wishes to begin breastfeeding. The nurse assists the client by:
- A. Positioning the infant to grasp the nipple to express milk.
- B. Giving the infant a bottle first to evaluate the baby's ability to suck
- C. Leaving them alone and allowing the infant to nurse as long as desired
- D. Touching the infant's cheek adjacent to the nipple to elicit the rooting reflex
Correct Answer: A
Rationale: Positioning the infant to grasp the nipple to express milk is an essential step in helping the patient begin breastfeeding successfully. As a nurse, it is crucial to ensure that the infant is properly latched onto the breast to facilitate effective feeding and milk transfer. This involves positioning the infant in a way that allows them to effectively grasp the nipple, promoting proper suckling and milk production. By assisting the patient in positioning the infant correctly, the nurse is supporting the establishment of successful breastfeeding and ensuring optimal nutrition for the baby.
A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. The nurse locates the fetal heart tones above the client's umbilicus at midline. The nurse should suspect that the fetus is in which of the following positions?
- A. Cephalic
- B. Transverse
- C. Posterior
- D. Frank breech
Correct Answer: A
Rationale: When the nurse locates the fetal heart tones above the client's umbilicus at midline, it indicates that the fetus is in a cephalic position. In this position, the baby's head is facing downward towards the birth canal, which is the optimal position for a vaginal delivery. This positioning is considered normal and favorable for childbirth.