A primigravid client with class II heart disease who is visiting the clinic at 8 weeks' gestation tells the nurse that she has been maintaining a low-sodium, 1,800-calorie diet. Which of the following instructions should the nurse give the client?
- A. Avoid folic acid supplements to prevent megaloblastic anemia.
- B. Severely restrict sodium intake throughout the pregnancy.
- C. Take iron supplements with milk to enhance absorption.
- D. Increase caloric intake to 2,200 calories daily to promote fetal growth.
Correct Answer: D
Rationale: Increased caloric intake supports fetal growth without compromising maternal health.
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A newly delivered client is asking to go to the bathroom 45 minutes after delivery. She had an epidural for labor & delivery, has an IV infusing, and every 15 minutes assessments are in progress. To provide the safest care for this client the nurse should:
- A. Ask her to remain in bed until the 15-minute assessments are complete.
- B. Assess client's ability to stand and bear weight before going to the bathroom.
- C. Encourage the client to sit at the side of the bed before ambulating to the bathroom.
- D. Ask the client to ambulate the first time with a staff member at her side.
Correct Answer: B
Rationale: Post-epidural, assessing the client's ability to stand and bear weight ensures safety due to potential residual numbness or weakness. Remaining in bed delays care, sitting first is insufficient, and ambulating with assistance assumes mobility not yet confirmed.
A multiparous client, 28 hours after cesarean delivery, who is breast-feeding complains of severe cramps or afterpains. The nurse explains that these are caused by which of the following?
- A. Flatulence accumulation after a cesarean delivery.
- B. Healing of the abdominal incision after cesarean delivery.
- C. Adverse effects of the medications administered after delivery.
- D. Release of oxytocin during the breast-feeding session.
Correct Answer: D
Rationale: Breastfeeding stimulates oxytocin release, causing uterine contractions (afterpains) as the uterus involutes.
The nurse is evaluating the client who delivered vaginally 2 hours ago and is experiencing postpartum pain rated 8 on scale of 1 to 10. The client is a G 4, P 4, breast-feeding mother who would like medication to decrease the pain in her uterus. Which of the medications listed on the orders sheet would be the most appropriate for this client?
- A. Aspirin 1,000 mg P.O. q 4 to 6 hour p.r.n.
- B. Ibuprofen 800 mg P.O. q 6 to 8 hour p.r.n.
- C. Colace 100 mg P.O. b.i.d.
- D. Vicodin 1 to 2 tabs P.O. q 4 to 6 hour p.r.n.
Correct Answer: B
Rationale: Ibuprofen is safe for breastfeeding mothers and effective for uterine cramping pain, unlike aspirin (risk of bleeding), Colace (stool softener), or Vicodin (opioid, less preferred due to sedation risks).
After instructing a mother about normal reflexes of term neonates, the nurse determines that the mother understands the instructions when she describes the tonic neck reflex as occurring when the neonate does which of the following?
- A. Steps briskly when held upright near a firm, hard surface.
- B. Pulls both arms and does not move the chin beyond the point of the elbows.
- C. Turns head to the left, extends left extremities, and flexes right extremities.
- D. Extends and abducts the arms and legs with the toes fanning open.
Correct Answer: C
Rationale: The tonic neck reflex involves the neonate turning the head to one side, extending the extremities on that side, and flexing the opposite side.
A 38-year-old client at about 14 weeks' gestation is admitted to the hospital with a diagnosis of complete hydatidiform mole. Soon after admission, the nurse would assess the client for signs and symptoms of which of the following?
- A. Pregnancy-induced hypertension.
- B. Gestational diabetes.
- C. Hypothyroidism.
- D. Polycythemia.
Correct Answer: A
Rationale: Pregnancy-induced hypertension is a common complication of hydatidiform mole.
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