Nokea
The maternity nurse is teaching a pregnant client about the physiological effects and hormone changes that occur in pregnancy. Which information should the nurse provide to the client about the purpose of estrogen?
- A. It maintains the uterine lining for implantation.
- B. It stimulates metabolism of glucose and converts the glucose to fat.
- C. It prevents the involution of the corpus luteum and maintains the production of progesterone until the placenta is formed.
- D. It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.
Correct Answer: D
Rationale: Estrogen stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation. Progesterone maintains the uterine lining for implantation and relaxes all smooth muscle. Human placental lactogen stimulates the metabolism of glucose and converts the glucose to fat. Human chorionic gonadotropin prevents involution of the corpus luteum and maintains the production of progesterone until the placenta is formed.
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The nurse is caring for a client who has just undergone a colectomy. Which of the following interventions is most important in the immediate postoperative period?
- A. Monitor for signs of bowel perforation.
- B. Encourage early ambulation.
- C. Administer oral fluids immediately.
- D. Keep the client on bed rest for 48 hours.
Correct Answer: B
Rationale: Encouraging early ambulation post-colectomy prevents complications like ileus and deep vein thrombosis.
A client's medical record states a history of intermittent claudication. In collecting data about this symptom, the nurse should ask the client about which symptom?
- A. Chest pain that is dull and feels like heartburn
- B. Leg pain that is sharp and occurs with exercise
- C. Chest pain that is sudden and occurs with exertion
- D. Leg pain that is achy and gets worse as the day progresses
Correct Answer: B
Rationale: Intermittent claudication is a symptom characterized by a sudden onset of leg pain that occurs with exercise and is relieved by rest. It is the classic symptom of peripheral arterial insufficiency. Chest pain can occur for a variety of reasons, including indigestion or angina pectoris. Venous insufficiency is characterized by an achy type of leg pain that intensifies as the day progresses.
Prochlorperazine (Compazine) is prescribed postoperatively. The nurse should evaluate the drug's therapeutic effect when the client expresses relief from which of the following?
- A. Nausea.
- B. Dizziness.
- C. Abdominal spasms.
- D. Abdominal distention.
Correct Answer: A
Rationale: Prochlorperazine is primarily used to treat postoperative nausea and vomiting, so relief from nausea indicates therapeutic effectiveness.
The nurse is caring for a client with a history of burns. Which of the following psychosocial interventions should be included in the plan of care?
- A. Encourage expression of feelings.
- B. Restrict family visits.
- C. Limit social interactions.
- D. Provide sedatives routinely.
Correct Answer: A
Rationale: Encouraging expression of feelings supports emotional coping in burn recovery.
A client with a history of bipolar disorder is prescribed lamotrigine (Lamictal). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild headache.
- B. Rash.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: A rash may indicate a serious hypersensitivity reaction to lamotrigine, such as Stevens-Johnson syndrome, requiring immediate reporting.