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In which of the following situations should a nurse report a possible deep vein thrombosis (DVT)?
- A. The woman complains of numbness in the toes and heel of one foot.
- B. The woman has cramping pain in a calf that is relieved when the foot is dorsiflexed.
- C. One of the woman's calves is swollen, red, and warm to the touch.
- D. The veins in the ankle of one of the woman's legs are spider-like and purple.
Correct Answer: C
Rationale: Swelling, redness, and warmth are classic signs of DVT.
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Which anticipatory guidance action by the nurse makes role transition to parenthood easier?
- A. Helps the new parents identify resources.
- B. Recommends employing babysitters frequently.
- C. Tells the parents about the realities of parenthoo
- D. Offers a home phone number and tells parents to call if they have a question.
Correct Answer: A
Rationale: The correct answer is A because helping new parents identify resources promotes a smoother role transition by providing support and guidance. This action empowers parents to access necessary services and assistance. Choice B is incorrect as frequent babysitting does not address the parents' transition needs. Choice C is incorrect because focusing on the negatives may increase anxiety. Choice D is incorrect as it lacks proactive support and guidance.
The nurse educates the non–breast-feeding person on breast discomfort caused by engorgement. What instructions would they give?
- A. Massage breasts to release milk.
- B. Apply cold packs and cabbage leaves.
- C. Stand in the warm shower to stimulate letdown.
- D. Do not wear a bra.
Correct Answer: B
Rationale: The correct answer is B: Apply cold packs and cabbage leaves. Engorgement causes breast swelling and discomfort due to increased blood and milk supply. Applying cold packs reduces inflammation and pain. Cabbage leaves have a cooling effect and can help reduce swelling. Massaging breasts can worsen engorgement by stimulating more milk production. Standing in a warm shower may provide temporary relief but does not address the root cause. Not wearing a bra may lead to discomfort and does not alleviate engorgement.
The nurse is assessing a neonate in the newborn nursery. Which of the following findings in a newborn should be reported to the neonatologist?
- A. The eyes cross and uncross when they are open.
- B. The ears are positioned in alignment with the inner and outer canthus of the eyes.
- C. Axillae and femoral folds of the baby are covered with a white cheesy substance.
- D. The nostrils flare whenever the baby inhales.
Correct Answer: D
Rationale: Nostril flaring indicates respiratory distress.
A nurse is teaching a mother how to care for her 3-day-old son's circumcised penis. Which of the following actions demonstrates that the mother has learned the information?
- A. The mother cleanses the glans with a cotton swab dipped in hydrogen peroxide.
- B. The mother covers the glans with antifungal ointment after rinsing off any discharge.
- C. The mother squeezes soapy water from the wash cloth over the glans.
- D. The mother replaces the dry sterile dressing before putting on the diaper.
Correct Answer: D
Rationale: Proper care involves keeping the area clean and dry, with a sterile dressing if necessary.
The nurse includes the addition of ice sitz baths for the postpartum patient. Which assessment finding indicates the treatment has been effective?
- A. No swelling or edema to the perineal area
- B. Patient complains that the sitz bath is too col
- C. Patient reports she took two sitz baths in 12 hours.
- D. Edges of the perineal laceration are well approximate
Correct Answer: A
Rationale: The correct answer is A because the absence of swelling or edema to the perineal area indicates that the ice sitz baths have been effective in reducing inflammation and promoting healing. Swelling and edema are common postpartum, and the use of ice sitz baths can help reduce these symptoms.
Choice B is incorrect because the patient complaining that the sitz bath is too cold does not provide information on the effectiveness of the treatment, only the patient's comfort level.
Choice C is incorrect because the frequency of sitz baths does not necessarily indicate effectiveness. It is more important to assess the outcomes of the treatment rather than the number of baths taken.
Choice D is incorrect because the approximation of perineal laceration edges may be influenced by other factors such as suturing technique, rather than the effectiveness of the ice sitz baths.