Nokea
Which is a priority nursing intervention for a post-operative patient who has had an incomplete abortion?
- A. Insertion of IV line and fluid replacement
- B. Methergine IM (Clerie said this one to diminish bleeding, but Quizlet said bolded answer)
- C. Positioning client on left side
- D. Preop teaching for surgery
Correct Answer: A
Rationale: The correct answer is A: Insertion of IV line and fluid replacement. This is the priority nursing intervention for a post-operative patient with an incomplete abortion because fluid replacement is essential to address potential hypovolemia from bleeding. Ensuring adequate IV access allows for prompt administration of fluids and medications to stabilize the patient's condition. Choice B, Methergine IM, may help reduce bleeding but is not the immediate priority. Choice C, positioning the client on the left side, is not as urgent as fluid replacement. Choice D, preop teaching for surgery, is not relevant in this post-operative scenario.
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Preexisting medical conditions like diabetes, hypertension, and autoimmune diseases can impact pregnancy outcomes. What education can the nurse provide?
- A. Your medical condition always gets worse during pregnancy.
- B. Nutrition changes cannot help with fertility.
- C. Maintaining glucose control can increase chances of conceiving.
- D. Autoimmune diseases only affect pregnancy, not infertility.
Correct Answer: C
Rationale: The correct answer is C: Maintaining glucose control can increase chances of conceiving. This is because uncontrolled diabetes can lead to complications during pregnancy, affecting both the mother and the baby. By educating the patient on the importance of managing their glucose levels, the nurse can help improve fertility outcomes.
A: Your medical condition always gets worse during pregnancy - Incorrect. Medical conditions may not always worsen during pregnancy, and managing them properly can lead to positive outcomes.
B: Nutrition changes cannot help with fertility - Incorrect. Nutrition plays a crucial role in fertility, and making appropriate dietary changes can improve the chances of conception.
D: Autoimmune diseases only affect pregnancy, not infertility - Incorrect. Autoimmune diseases can impact fertility as well as pregnancy outcomes, so it is important to address these conditions when trying to conceive.
The nurse is teaching a client about postpartum care. Which statement indicates a need for further teaching?
- A. I will avoid heavy lifting for 6 weeks.
- B. It’s normal to have heavy bleeding for 4 weeks.
- C. I will call my doctor if I develop a fever.
- D. I should continue taking my prenatal vitamins.
Correct Answer: B
Rationale: The correct answer is B because heavy bleeding for 4 weeks postpartum is abnormal and could indicate a complication. The client should seek medical attention if experiencing heavy bleeding beyond the normal range. Choices A, C, and D are all correct statements for postpartum care. A - avoiding heavy lifting helps prevent strain on healing tissues, C - fever could indicate infection, and D - continuing prenatal vitamins supports postpartum recovery.
A 28-year-old G1 P0 client tells the nurse that she medication cabergoline, which is effective in reducing has a craving for chalk. What is the nurse's best prolactin levels. What are possible side effects of this response to her?
- A. That is not normal for anyone. We need to refer
- B. Hypotension you to a therapist.
- C. Nasal congestion
- D. Tell me more about why you have a craving for it.
Correct Answer: D
Rationale: Step 1: The nurse should engage the client to gather more information about the craving for chalk. This helps in understanding the underlying cause.
Step 2: By asking the client to elaborate on the reason for the craving, the nurse can assess if it's related to a medical condition or nutritional deficiency.
Step 3: Understanding the client's perspective can guide the nurse in providing appropriate support and interventions.
Step 4: Referring the client to a therapist (option A) without first exploring the issue may not address the root cause effectively.
Step 5: Hypotension (option B) and nasal congestion (option C) are not directly related to the issue of chalk craving, making them incorrect choices.
In summary, option D is correct as it promotes client-centered care by exploring the client's concerns before considering further interventions.
A nurse on a labor and delivery unit is receiving infection control standards with a newly licensed nurse. The nurse should instruct the newly licensed nurse to don gloves for which of the following procedures?
- A. Assisting a mother with breastfeeding
- B. Performing a newborn's initial bath
- C. Administering the measles, mumps, rubella vaccine
- D. Performing umbilical cord care
Correct Answer: D
Rationale: The correct answer is D: Performing umbilical cord care. Gloves should be worn during this procedure to prevent the spread of infection. The umbilical cord stump is a potential entry point for bacteria, so gloves are necessary to maintain asepsis.
A: Assisting a mother with breastfeeding does not require gloves as it is a clean procedure.
B: Performing a newborn's initial bath does not require gloves unless there are open wounds on the newborn.
C: Administering the measles, mumps, rubella vaccine may require gloves, but the primary concern is needlestick safety rather than infection control through glove use.
The nurse should designate the highest priority health outcomes to be:
- A. Oxygenation will remain adequate
- B. Body temperature will remain stable
- C. Weight will increase by 30g per day
- D. Heart rate will recover to an acceptable range
Correct Answer: A
Rationale: The correct answer is A because adequate oxygenation is a critical health outcome necessary for cellular function and overall well-being. Without sufficient oxygenation, other bodily functions can be compromised. Stable body temperature (B) is important but not as immediately life-threatening as inadequate oxygenation. Weight gain (C) is not a priority health outcome in this scenario. Heart rate recovery (D) is important but ensuring adequate oxygenation takes precedence in this case.