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Prophylactic heparin therapy is ordered to treat thrombophlebitis in a multiparous client who delivered 24 hours ago. After instructing the client about the medication, the nurse determines that the client understands the instructions when she states which of the following as the purpose of the drug?
- A. To thin the blood clots.
- B. To increase the lochial flow.
- C. To increase the perspiration for diuresis.
- D. To prevent further blood clot formation.
Correct Answer: D
Rationale: Heparin prevents further clot formation in thrombophlebitis without dissolving existing clots.
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A nurse is counseling a client about the use of a vaginal contraceptive ring. Which of the following client statements indicates understanding?
- A. I should remove the ring every night before bed.
- B. The ring is left in place for three weeks, then removed for one week.
- C. I need to replace the ring every two weeks.
- D. The ring protects against HIV transmission.
Correct Answer: B
Rationale: The vaginal contraceptive ring is left in place for three weeks, then removed for one week to allow a withdrawal bleed. It is not removed nightly, replaced every two weeks, or protective against HIV.
While caring for a primigravid client with class II heart disease at 28 weeks' gestation, the nurse would instruct the client to contact her physician immediately if the client experiences which of the following?
- A. Mild ankle edema.
- B. Emotional stress on the job.
- C. Weight gain of 1 lb in 1 week.
- D. Increased dyspnea at rest.
Correct Answer: D
Rationale: Increased dyspnea at rest can indicate worsening heart function.
A nurse is counseling a client about the vaginal contraceptive ring. Which of the following client statements indicates a need for further teaching?
- A. I will leave the ring in place for three weeks.
- B. I may experience nausea or breast tenderness.
- C. I can remove the ring for up to 3 hours if needed.
- D. The ring will make my periods heavier.
Correct Answer: D
Rationale: The vaginal contraceptive ring typically reduces menstrual flow or causes lighter periods, not heavier ones. The other statements are correct, indicating a need for further teaching about menstrual effects.
A multigravid client in active labor at 39 weeks' gestation has a history of smoking one to two packs of cigarettes daily. For which of the following should the nurse be alert when assessing the client's neonate?
- A. Hyperirritability.
- B. Hyperbilirubinemia.
- C. Low birth weight.
- D. Hypocalcemia.
Correct Answer: C
Rationale: Maternal smoking is strongly associated with low birth weight due to placental insufficiency and reduced fetal growth. Hyperirritability, hyperbilirubinemia, and hypocalcemia are less directly linked.
The nurse assesses a primiparous client in labor for 20 hours. The nurse identifies late decelerations on the monitor and initiates standard procedures for the labor client with this wave pattern. Which intravenous should the nurse perform? Select all that apply.
- A. Administering oxygen via mask to the client.
- B. Questioning the client about the effectiveness of pain relief.
- C. Placing the client on her side.
- D. Readjusting the monitor to a more comfortable position.
- E. Applying an internal fetal monitor to help identify the cause of the decelerations.
Correct Answer: A,C
Rationale: Late decelerations indicate uteroplacental insufficiency. Standard interventions include administering oxygen to improve fetal oxygenation and placing the client on her side to enhance uterine perfusion. Questioning pain relief or readjusting the monitor does not address the issue, and internal monitoring may be considered but is not the first step.