Nokea
In the process of preparing the client for discharge after cesarean section, the nurse addresses all of the following areas during discharge education. Which should be the priority advice for the client?
- A. How to manage her incision
- B. Planning for assistance at home
- C. Infant care procedures
- D. Increased need for rest
Correct Answer: B
Rationale: Although the client needs information about incision care, the priority need is for assistance at home so that she can get the rest needed for multiple demands. Because the client has had a surgical procedure, the priority consideration is for the mother to plan for additional assistance at home. Without this assistance, it is difficult for the mother to get the rest she needs for healing, pain control, and appropriate infant care. Infant care is important, but having assistance at home after a surgical procedure is more important. The need for increased rest is important, but she would not be able to obtain adequate rest without assistance at home.
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The nurse is caring for the client admitted to the antepartum unit at 32 weeks’ gestation with possible preterm labor. The nurse is performing a fetal fibronectin (fFN) test. Which event, if it occurred, would require the nurse to recollect the specimen?
- A. The specimen is collected before a vaginal examination.
- B. A lubricant was used to facilitate insertion of the swab.
- C. The client reports that she has not had intercourse for 3 days.
- D. The specimen is collected before other specimens are collected.
Correct Answer: B
Rationale: When collecting a fetal fibronectin test swab, the nurse must not use lubricant, as it will interfere with the collection of the specimen and contaminate the specimen. If this occurs, the test will need to be repeated. The specimen needs to be collected before a vaginal examination in order to ensure that the fluids are not contaminated. The client must not have had sexual intercourse within 24 hours of the specimen collection, as semen will contaminate the specimen. The specimen must be collected before other specimens are collected to maintain the integrity of the specimen.
Which activity should the nurse recommend to prepare for labor?
- A. Practicing relaxation and breathing techniques
- B. Increasing caffeine intake
- C. Avoiding all physical activity
- D. Taking daily hot baths
Correct Answer: A
Rationale: Practicing relaxation and breathing techniques helps manage labor pain and prepares the client for childbirth.
The postpartum client, who had a forceps-assisted vaginal birth 4 hours ago, tells the nurse that she is having continuing perineal pain rated at 7 out of 10 and rectal pressure. An oral analgesic was given and ice applied to the perineum earlier. What should the nurse do now?
- A. Call the HCP to report the pain
- B. Closely reinspect the perineum
- C. Help her out of bed to ambulate
- D. Administer a stool softener
Correct Answer: B
Rationale: Reexamination of the perineum should be completed before calling the HCP to report the pain level. A forceps-assisted delivery can increase the risk of hematoma development. Rectal pressure and perineal pain can indicate a hematoma in the posterior vaginal wall. The nurse should closely examine the perineum and the vaginal introitus for ecchymosis and a bulging mass. Ambulation would not help the perineal pain. A stool softener would be appropriate to avoid constipation but would not help the immediate problem.
The nurse is providing nutrition counseling to a primigravida who is 10 weeks pregnant. Which meal choice stated by the client indicates she needs additional information?
- A. Black beans, wild rice, collard greens
- B. Dry cereal, milk, dried cranberries
- C. Tuna, broccoli, baked potato
- D. Beef strips, lentils, red peppers
Correct Answer: C
Rationale: Tuna contains mercury and should be limited in pregnancy due to risk of mercury poisoning. The nurse should provide this additional information. Black beans provide a good source of calcium, iron, and protein. Black beans, wild rice, and collard greens provide fiber. Collard greens provide a good source of calcium and folic acid. Dry cereal provides a good source of vitamin D, milk provides a good source of calcium, and dried cranberries provide a good source of calcium and iron. Beef provides a good source of protein and iron, lentils provide a good source of iron, and red peppers provide a good source of vitamin C.
Which assessment finding best indicates the presence of this condition?
- A. Painful blisters on the labia
- B. Heavy, grayish white discharge
- C. Milky white discharge that smells like fish
- D. Thick, white, curdlike vaginal discharge
Correct Answer: B
Rationale: Chlamydia often presents with heavy, grayish-white discharge, unlike the other options, which suggest different infections.