Nokea
A nurse is reviewing the electronic medical record of a postpartum client. The nurse should identify that which of the following factors paces the client at risk for infection.
- A. Meconium – start fluid
- B. placenta previa
- C. Midline episiotomy
- D. Prolonged labor
Correct Answer: C
Rationale: The correct answer is C: Midline episiotomy. Midline episiotomies are associated with a higher risk of infection due to the location being close to the anal canal, which harbors bacteria. The incision can become contaminated during bowel movements or urination, increasing the risk of infection. Placenta previa (B) is a condition related to the positioning of the placenta, not directly associated with infection risk. Meconium-stained amniotic fluid (A) may indicate fetal distress but does not directly increase the mother's risk of infection. Prolonged labor (D) can lead to increased risk of infection due to prolonged exposure to vaginal flora, but it is not as direct a risk factor as a midline episiotomy.
You may also like to solve these questions
A nurse is teaching about clomiphene citrate to a client who is experiencing infertility. Which of the following adverse effect should the nurse include?
- A. Tinnitus
- B. Urinary Frequency
- C. Breast Tenderness
- D. Chills
Correct Answer: C
Rationale: The correct answer is C: Breast Tenderness. Clomiphene citrate is a medication commonly used for infertility, and a common side effect is breast tenderness due to its estrogen-like effects on the body. Tinnitus (A), urinary frequency (B), and chills (D) are not typically associated with clomiphene citrate. Tinnitus could be related to ototoxic medications, urinary frequency could be due to diuretics, and chills could be due to infections or allergic reactions, but they are not commonly linked to clomiphene citrate. Therefore, the nurse should focus on educating the client about the potential adverse effect of breast tenderness when taking clomiphene citrate.
A nurse is caring for a client who is in the second stage of labor. Which of the following manifestations should the nurse expect?
- A. The client expels the placenta
- B. The client experiences gradual dilation of the cervix
- C. The client begins have regular contractions.
- D. The client delivers the newborn
Correct Answer: D
Rationale: The correct answer is D. In the second stage of labor, the client delivers the newborn. This stage begins with full dilation of the cervix and ends with the birth of the baby. The expulsion of the placenta (Choice A) occurs in the third stage of labor. Gradual dilation of the cervix (Choice B) is characteristic of the first stage of labor. Regular contractions (Choice C) may occur throughout labor but are not specific to the second stage. So, the correct answer is D because it aligns with the chronological progression of labor stages.
A nurse is assessing a client who is 27 weeks of gestation and has pre-eclampsia. Which of the following findings should the nurse report to the provider?
- A. Hemoglobin 14.8 g/dL
- B. Platelet count 60,000/mm³
- C. Creatinine 0.8 mg/dL
- D. Urine protein concentration 200 mg/24hr
Correct Answer: B
Rationale: The correct answer is B: Platelet count 60,000/mm³. In pre-eclampsia, there is a risk of developing HELLP syndrome, which includes hemolysis, elevated liver enzymes, and low platelet count. A platelet count of 60,000/mm³ indicates thrombocytopenia, a serious complication that can lead to bleeding and should be reported to the provider urgently. Choices A, C, and D are within normal limits for a pregnant client and are not indicative of an immediate concern in pre-eclampsia.
A nurse is teaching a client who is at 41 weeks of gestation about a non-stress test. Which of the following information should the nurse include in the teaching?
- A. This test will confirm fetal lung maturity
- B. This test will determine adequacy of placental perfusion
- C. This test will detect fetal infection
- D. This test will predict maternal readiness for labor
Correct Answer: B
Rationale: The correct answer is B: This test will determine the adequacy of placental perfusion. A non-stress test is used to assess fetal well-being by monitoring the fetal heart rate in response to fetal movement. The test helps determine if the placenta is providing enough oxygen to the fetus. Adequate placental perfusion is crucial for the well-being of the fetus. Option A is incorrect because a non-stress test does not confirm fetal lung maturity. Option C is incorrect because a non-stress test does not detect fetal infection. Option D is incorrect because a non-stress test does not predict maternal readiness for labor.
A nurse is providing teaching to a client who is receiving medroxyprogesterone IM for contraception. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should discontinue this medication if I experience spotting
- B. I will need to return to the clinic in the next eight weeks for my next injection
- C. I should increase my calcium intake while taking this medication
- D. I will get two shots each time I receive this medication
Correct Answer: B
Rationale: The correct answer is B. Returning to the clinic in 8 weeks for the next injection indicates an understanding of the medication schedule. Medroxyprogesterone is typically given every 11 to 13 weeks, so returning in 8 weeks would align with the correct timing for the next injection. This demonstrates the client's comprehension of the dosing regimen.
Incorrect choices:
A: Discontinuing the medication if spotting occurs is not correct as spotting can be a common side effect of medroxyprogesterone.
C: Increasing calcium intake is not specifically related to medroxyprogesterone IM for contraception.
D: Getting two shots each time is incorrect as typically only one injection is given.
Overall, choice B is the correct answer based on the medication's dosing schedule, while the other choices do not align with the appropriate understanding of medroxyprogesterone IM for contraception.