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A postpartum client who delivered vaginally expresses concern about feeling "heavy" in the perineal area. What education should the nurse provide to address this sensation?
- A. Encourage the client to perform Kegel exercises regularly.
- B. Recommend the use of perineal pads for additional support.
- C. Educate the client about the process of uterine involution.
- D. Suggest the use of a perineal support garment.
Correct Answer: A
Rationale: The sensation of feeling "heavy" in the perineal area postpartum is a common concern due to the stretching and potential trauma to the perineal muscles during childbirth. Kegel exercises are specifically designed to strengthen the pelvic floor muscles, which can help alleviate this sensation of heaviness. By encouraging the client to perform Kegel exercises regularly, the nurse is promoting the restoration and strengthening of the perineal muscles, ultimately helping the client feel more comfortable and supported in that area. This education empowers the client to take an active role in their own recovery and promotes optimal healing postpartum.
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A primigravida at 39 weeks gestation presents to the labor and delivery unit with contractions every 5 minutes, lasting 45 seconds each. On examination, her cervix is dilated to 3 cm. What is the appropriate nursing intervention?
- A. Encourage the mother to walk to facilitate labor progression.
- B. Administer oxytocin to augment labor.
- C. Prepare for cesarean section.
- D. Encourage relaxation techniques to manage pain.
Correct Answer: A
Rationale: The appropriate nursing intervention in this case is to encourage the mother to walk to facilitate labor progression. The patient is in early labor with contractions every 5 minutes, lasting 45 seconds each, and her cervix is dilated to 3 cm. Encouraging the mother to walk can help gravity assist the descent of the baby and promote cervical dilation. Walking can also help alleviate some discomfort and encourage labor progression. It is important to promote natural, non-invasive methods to support the progress of labor before considering medical interventions such as oxytocin or cesarean section. Relaxation techniques can also be beneficial in managing pain during labor.
To remove the ingested poisonous substance, the physician ordered a gastric lavage. What is the role of the nurse immediately prior to the procedure?
- A. Get the right size of the nasogastric tube
- B. Remind parents to be careful next time
- C. Obtain an informed consent immediately
- D. Tell the parent that they are negligent
Correct Answer: A
Rationale: Prior to a gastric lavage procedure, it is essential for the nurse to ensure the correct size of the nasogastric tube is selected. The appropriate size of the tube will allow for effective removal of the ingested poisonous substance during the procedure. Proper sizing also helps in preventing complications such as injury to the gastrointestinal tract or inadequate removal of the substance. This step is crucial for the safe and successful completion of gastric lavage. Reminding parents to be careful, obtaining informed consent immediately, or accusing them of negligence are not immediate responsibilities of the nurse in this context.
Which of the following actions is a violation of a psychiatric patient's rights?
- A. Paranoid patient with delusions about his family is told that if he makes a will, it might not be valid.
- B. The nurse confiscated the cellphone from patient's room and tell him it is being locked in the vault.
- C. Staff members confiscated written letters done by patients addressed to local newspaper.
- D. Patient is paid minimum wage for helping in the hospital kitchen.
Correct Answer: C
Rationale: In this scenario, the action that violates a psychiatric patient's rights is option C, where staff members confiscated written letters done by patients addressed to the local newspaper. Patients have the right to communicate freely and express their thoughts and feelings through various means, such as letter-writing. Confiscating these letters is a violation of their rights to free expression and communication. It is essential to respect and uphold the rights of psychiatric patients, including their right to communicate with others.
A pregnant woman presents with lower abdominal pain, fever, and vaginal discharge. On examination, cervical motion tenderness and bilateral adnexal tenderness are noted. Which of the following conditions is the most likely cause of these symptoms?
- A. Ectopic pregnancy
- B. Pelvic inflammatory disease
- C. Placenta previa
- D. Ovarian torsion
Correct Answer: B
Rationale: Pelvic inflammatory disease (PID) is the most likely cause of the symptoms described in the pregnant woman. PID is an infection of the female reproductive organs, typically caused by sexually transmitted bacteria like Chlamydia or Gonorrhea. The classic presentation includes lower abdominal pain, fever, vaginal discharge, cervical motion tenderness, and bilateral adnexal tenderness on examination. This condition can lead to serious complications if not promptly treated, including infertility, ectopic pregnancy, and chronic pelvic pain. Therefore, it is crucial to diagnose and manage PID promptly, especially in pregnant women, to prevent adverse outcomes.
Which of the following IS TRUE about osteoporosis
- A. it is a silent disease
- B. It is more common in men
- C. it is not that alarming
- D. It is only discovered after a fracture
Correct Answer: A
Rationale: Osteoporosis is known as a "silent disease" because it develops slowly over time without any symptoms. Many people with osteoporosis are unaware of their condition until they experience a fracture. The loss of bone density and strength in osteoporosis occurs without any obvious warning signs, making it important for individuals at risk to undergo bone density testing to identify the condition early and prevent further bone loss.