Nokea
A nurse on a postpartum unit is receiving change-of-shift report for four clients. Which of the following.....
- A. A client who gave a birth 1 day ago and needs Rh˳(D) immune globulin.
- B. A client who gave a birth 3 days ago and reports breath fullness.
- C. A client who gave a birth 12 hr. ago and reports and increase in urinary output.
- D. A client who gave a birth 8 hr. ago and is saturating a perineal pad every hour.
Correct Answer: B
Rationale: The client who gave birth 3 days ago and reports breath fullness is showing signs of potential postpartum complications, such as a pulmonary embolism. Pulmonary embolism is a serious condition that can occur postpartum due to blood clot formation. Symptoms like breath fullness, chest pain, and shortness of breath should never be ignored in postpartum clients. This client requires immediate assessment and intervention to prevent further complications. The other options are concerning but do not indicate as urgent of a situation as breath fullness, which could be a life-threatening issue.
You may also like to solve these questions
The nurse is educating a client about kick counts. When should the client contact the healthcare provider?
- A. Fewer than 10 movements in 2 hours.
- B. Fewer than 5 movements in 1 hour.
- C. No movements after drinking juice.
- D. No movements for 12 hours.
Correct Answer: A
Rationale: Fewer than 10 movements in 2 hours is concerning and warrants further evaluation.
Mother in late middle age who is certain she is not pregnant tells
the nurse during an office visit she has urinary problems as well as
sensation of bearing down and of something in the vagina. The nurse
should realize that the client is most likely suffering from:
- A. Uterine prolapse
- B. Cystocele/rectocele
- C. Urinary tract infection (UTI)
- D. Endometriosis
Correct Answer: B
Rationale: A cystocele/rectocele occurs when the supportive tissue between a woman's bladder and vaginal wall weakens, allowing the bladder to bulge into the vagina. This can lead to urinary problems such as difficulty emptying the bladder completely, frequent urination, and urinary incontinence. The fact that the mother is in late middle age and certain she is not pregnant, combined with her urinary problems, suggests that she may be experiencing symptoms of a cystocele/rectocele. It is important for the nurse to further assess the client's symptoms and provide appropriate education and treatment options.
A nurse educator is teaching a class to nursing developing cervical cancer. Which client is at students about the incidence of sexually transmitted highest risk? infections (STIs) and their impact on public health.
- A. Client with a Pap test and an HPV screen positive Which is the most commonly reported STI in the for type 12 United States?
- B. Client who is 40 years old and stopped smoking
- C. Syphilis
- D. Gonorrhea
Correct Answer: A
Rationale: Human papillomavirus (HPV) is the most commonly reported sexually transmitted infection (STI) in the United States. HPV infection, especially high-risk types such as HPV-16, is strongly associated with cervical cancer. Therefore, a client who is positive for HPV type 16 on an HPV screen is at the highest risk for developing cervical cancer among the given choices. The nurse educator would need to emphasize the importance of regular screening, follow-up, and prevention strategies for this client to reduce the risk of cervical cancer development.
Two hours after an epidural infusion has begun the patient complains of itching of her face and neck. The nurse should:
- A. Recognize this is a common side effect to follow protocol for administration of Benadryl
- B. Remove the epidural catheter and apply a band aid on the injection site
- C. Offer the patient a cool cloth and let her know itching is temporary
- D. Call anesthesia to remove epidural catheter
Correct Answer: A
Rationale: Itching of the face and neck following an epidural infusion is a common side effect known as pruritus. The nurse should recognize this symptom and follow the protocol for addressing itching associated with epidural infusions. In this case, administering Benadryl is a common intervention to help relieve the itching. Benadryl is an antihistamine that can help alleviate itching and discomfort without the need to remove the epidural catheter. It is important for the nurse to assess the patient's symptoms, follow proper protocols, and provide appropriate interventions to manage side effects like pruritus.
Which of the following best describes the mechanism of action of birth control pills?
- A. They block sperm from reaching the egg.
- B. They prevent ovulation by suppressing hormone levels.
- C. They increase cervical mucus production to block sperm entry.
- D. They reduce the size of the ovaries and fallopian tubes to prevent pregnancy.
Correct Answer: B
Rationale: Birth control pills primarily work by preventing ovulation, thereby inhibiting the release of eggs for fertilization. Choice A is incorrect because birth control pills do not directly block sperm; they prevent ovulation. Choice C is partially correct but is not the main mechanism, as the primary function is to prevent ovulation. Choice D is incorrect because birth control pills do not alter the size of reproductive organs.