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A pregnant client receives Rho(D) immune globulin after an amniocentesis. The day following, she reports a temperature of 99.8°F (37.67°C). Which action should the nurse implement?
- A. Schedule a visit with the healthcare provider today.
- B. Verify the compatibility of the administered Rho(D) immune globulin.
- C. Encourage the client to increase her intake of oral fluids.
- D. Instruct the client to maintain bedrest for 24 hours.
Correct Answer: C
Rationale: A mild increase in temperature post-amniocentesis is common, and encouraging the client to increase oral fluid intake is the appropriate action. Increasing fluid intake can help reduce mild fever, promote recovery, and prevent dehydration. It is important for the nurse to educate the client on the importance of staying hydrated to support her overall well-being during this time.
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A 28-year-old client in active labor complains of cramps in her leg. What intervention should be implemented?
- A. Massage the calf and foot.
- B. Extend the leg and dorsiflex the foot.
- C. Lower the leg off the side of the bed.
- D. Elevate the leg above the heart.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
After breastfeeding for 10 minutes at each breast, a new mother calls the nurse to the postpartum room to help change the newborn's diaper. As the mother begins the diaper change, the newborn spits up the breast milk. What action should the nurse implement first?
- A. Wipe away the spit-up and assist the mother with the diaper change.
- B. Sit the newborn upright and burp by rubbing or patting the upper back.
- C. Place the newborn in a position with the head lower than the feet.
- D. Turn the newborn to the side and use bulb suction for the mouth and nares.
Correct Answer: B
Rationale: After a newborn spits up breast milk following feeding, the priority action for the nurse is to sit the newborn upright and burp by rubbing or patting the upper back. This position helps release trapped air and reduces the likelihood of further spit-up or aspiration. It is essential to address this first to prevent potential complications and ensure the newborn's comfort and safety.
A client who is 32 weeks' gestation comes to the women's health clinic and reports nausea and vomiting. On examination, the nurse notes that the client has an elevated blood pressure. Which action should the nurse implement next?
- A. Inspect the client's face for edema.
- B. Ascertain the frequency of headaches.
- C. Evaluate for a history of cluster headaches.
- D. Observe and time the client's contractions.
Correct Answer: A
Rationale: Inspecting the client's face for edema is crucial to assess for preeclampsia, a serious condition characterized by high blood pressure during pregnancy. Edema, particularly facial edema, can be a significant indicator of preeclampsia, prompting the need for further evaluation and management to ensure the well-being of both the client and the unborn child.
A 10-year-old is admitted to the orthopedic unit with a diagnosis of slipped femoral capital epiphysis (SFCE). What focus should the nurse include in this child's plan of care?
- A. Ambulation with a walking cast.
- B. Pin and incision care after surgery.
- C. Use of injections for pain control.
- D. Administration of growth hormone.
Correct Answer: B
Rationale: In the case of slipped femoral capital epiphysis, surgical intervention is often required. Post-surgery care is crucial to prevent complications such as infection and ensure proper healing. This care includes monitoring and managing pin and incision sites for signs of infection, promoting wound healing, and preventing postoperative complications. The focus on pin and incision care is essential for the child's recovery and overall well-being.
A pregnant woman in her first trimester is experiencing watery vaginal discharge. What should the nurse tell her?
- A. Inform her that it is normal.
- B. Advise her to see a doctor immediately.
- C. Suggest using panty liners.
- D. Suggest a change in diet.
Correct Answer: A
Rationale: Informing the pregnant woman that watery vaginal discharge is normal during the first trimester is crucial to providing reassurance and reducing anxiety. This discharge, known as leukorrhea, is common during pregnancy due to increased estrogen levels and increased blood flow to the pelvic area. It helps maintain a healthy balance of bacteria in the vagina and protects the birth canal from infection. Advising the woman to see a doctor immediately may cause unnecessary alarm, while suggesting the use of panty liners can help manage the discharge comfortably. Suggesting a change in diet is not relevant to addressing watery vaginal discharge in this scenario.