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A nurse is reviewing a laboratory results for a client who is at 33 weeks of gestation and has preeclampsia. Which of the following laboratory results should the nurse report to the provider?
- A. BUN 35 mg/dL
- B. Hgb 15 mg/dL
- C. Bilirubin 0.6 mg/dL
- D. Hct 37%
Correct Answer: A
Rationale: The correct answer is A: BUN 35 mg/dL. In preeclampsia, elevated BUN levels indicate impaired kidney function, a serious complication. High BUN can lead to renal damage. Hgb, Hct, and Bilirubin levels are within normal ranges for pregnancy, so they do not indicate a critical issue. Reporting BUN level is crucial for monitoring kidney function and preventing further complications in preeclampsia.
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What can self-awareness with postural adjustments lead to?
- A. tension formation
- B. tension release
- C. suboptimal posture
- D. back pain
Correct Answer: B
Rationale: Self-awareness with postural adjustments can lead to tension release because it allows individuals to identify and correct any muscular imbalances or poor postural habits. By being aware of their body positioning and making necessary adjustments, individuals can reduce muscle tension and promote proper alignment, leading to relaxation and alleviation of tension. This proactive approach helps prevent the buildup of tension in muscles, ultimately promoting overall well-being.
Incorrect Choices:
A: Tension formation - Self-awareness with postural adjustments helps prevent tension formation by addressing imbalances.
C: Suboptimal posture - Self-awareness promotes optimal posture by making adjustments.
D: Back pain - Proper postural adjustments can alleviate back pain, not cause it.
Which nursing intervention can help prevent postpartum depression?
- A. Provide printed educational material
- B. Encourage the mother to join a support group
- C. Assess the mother for risk factors of depression
- D. Administer antidepressants as prescribed
Correct Answer: B
Rationale: The correct answer is B because joining a support group can provide emotional support and reduce feelings of isolation, which are key factors in preventing postpartum depression. Printed educational material (A) may not offer personalized support. Assessing for risk factors (C) is important but alone may not prevent depression. Administering antidepressants (D) is a treatment, not a prevention strategy.
A nurse is reinforcing teaching about reducing perineal infection with a client following a vaginal delivery. Which of the following should the nurse include in the teaching? (Select all that apply.)
- A. Blot the perineal area dry after cleansing.
- B. Clean the perineal area from front to back.
- C. Perform hand hygiene before and after voiding.
- D. Wash the perineal area using a squeeze bottle of warm water after each voiding.
Correct Answer: A
Rationale: Correct Answer: A - Blot the perineal area dry after cleansing.
Rationale: Blotting the perineal area dry after cleansing helps prevent moisture accumulation, reducing the risk of perineal infection. Moisture can create a favorable environment for bacterial growth and infection. This practice also helps maintain skin integrity and promotes healing post-vaginal delivery.
Summary of other choices:
B: Cleaning the perineal area from front to back is important to prevent introducing fecal bacteria to the urinary tract but is not directly related to reducing perineal infection.
C: Performing hand hygiene before and after voiding is crucial for infection prevention but does not directly address reducing perineal infection.
D: Washing the perineal area using a squeeze bottle of warm water after each voiding can be beneficial for cleanliness but does not specifically address reducing perineal infection like blotting dry after cleansing does.
A young girl comes to the OB-GYN office to begin contraception. What is the most important information the nurse should find in the history before starting a contraceptive?
- A. Do your cramps prevent you from daily activities?
- B. When was your last menstrual period?
- C. How much water do you drink?
- D. How many pads do you soak per day during your cycle?
Correct Answer: A
Rationale: The correct answer is A: "Do your cramps prevent you from daily activities?" This question is crucial as it assesses the impact of menstrual cramps on the girl's quality of life, helping determine the suitability of different contraceptive options. Options B, C, and D are irrelevant to contraceptive choice and do not provide pertinent information regarding the girl's health or contraceptive needs.
Induction of labor is planned for 31-year-old primigravida 39 weeks. She has insulin dependent diabetes. Which nursing action is more important?
- A. Begin Pitocin 4h after Cytotec (thin the cervix first)
- B. Administer 100mcg Cytotec q2h(no)
- C. Place vaginal gel and ambulate patient 1h
- D. Prepare to induce labor after administering tap water enema
Correct Answer: A
Rationale: The correct answer is A: Begin Pitocin 4h after Cytotec. This is the most important nursing action because it follows the recommended protocol for inducing labor in a diabetic patient. Cytotec is used to thin the cervix, and waiting 4 hours before starting Pitocin reduces the risk of uterine hyperstimulation, which can be dangerous for the mother and baby. Administering Cytotec every 2 hours (choice B) can increase the risk of hyperstimulation. Placing vaginal gel and ambulating the patient (choice C) may not be appropriate in this case as the patient has diabetes. Preparing to induce labor after administering a tap water enema (choice D) is not a priority compared to ensuring a safe induction process for a diabetic patient.