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A nurse is conducting a discharge teaching for a client going home after cesarean section. Which S&S should the client be taught to report?
- A. Frequency urgency and burning on urination
- B. Feeling pelvic fullness
- C. Redness or edema of abdominal decision
- D. Mild incisional pain
Correct Answer: A
Rationale: After a cesarean section, the client should be taught to report symptoms of a urinary tract infection, such as frequency, urgency, and burning on urination. These symptoms can indicate an infection which needs prompt treatment to prevent complications. It is important for the client to report these symptoms to their healthcare provider for appropriate evaluation and management.
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Which of the following interpretations of this finding should the nurse make?
- A. The presenting part is 1 cm above the ischial spines.
- B. The presenting part is 1 cm below the ischial spines.
- C. The cervix is 1 cm dilated.
- D. The cervix is effaced 1 cm.
Correct Answer: A
Rationale: The finding of "station -1" indicates that the presenting part of the baby is 1 cm above the ischial spines in the mother's pelvis. Station is a measurement used in obstetrics to describe the position of the presenting part of the fetus in relation to the ischial spines of the mother's pelvis during labor. Stations are measured in centimeters and range from -5 (highest) to +5 (lowest). In this case, a station of -1 means the baby's presenting part is 1 cm above the ischial spines. This information helps healthcare providers assess the progress of labor and determine the positioning of the baby during delivery.
A patient calls and says she used her diaphragm on Saturday night at 8:00 p.m., again on Sunday morning at 2:00 a.m., and again at 8:00 a.m. She is wondering when she can safely remove it while still having effective contraception. What is the nurse’s best response?
- A. 10:00 a.m. Sunday
- B. 2:00 p.m. Sunday
- C. 10:00 p.m. Sunday
- D. 8:00 a.m. Monday
Correct Answer: D
Rationale: In general, a diaphragm should be left in place for at least 6 hours after intercourse but no more than 24 hours. Based on the patient's usage times on Saturday night at 8:00 p.m., Sunday morning at 2:00 a.m., and Sunday morning at 8:00 a.m., she can safely remove the diaphragm on Monday morning at 8:00 a.m. This ensures she has used it for the necessary timeframe for effective contraception.
A nurse is admitting a client who is at 33 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse take?
- A. Restrict protein intake to less than 40 g/day.
- B. Initiate seizure precautions for the client.
- C. Initiate an infusion of 0.9% sodium chloride at 150 mL/hr.
- D. Encourage the client to ambulate twice per day.
Correct Answer: B
Rationale: In a client with preeclampsia with severe features at 33 weeks of gestation, initiating seizure precautions is a priority nursing action. Preeclampsia with severe features places the client at an increased risk for seizures. Therefore, the nurse should ensure that seizure precautions are in place, such as maintaining a safe environment, pad the side rails of the bed, and have emergency medications and equipment readily available. Monitoring for signs and symptoms of worsening preeclampsia and impending seizures is crucial for the client's safety and well-being.
The breastfeeding mother should be taught a safe method to remove the breast from the baby's mouth? Which suggestion by the nurse is most appropriate?
- A. Break suction by inserting finger into corner of the infant mouth
- B. Elicit the moro reflex
- C. A popping sound
- D. Slowly remove breast from baby's mouth when the infant's mouth
Correct Answer: A
Rationale: The most appropriate suggestion by the nurse is to break the suction by gently inserting a clean finger into the corner of the infant's mouth. This method will safely release the baby's latch without causing any discomfort or injury to the baby or the mother. It is important to break the suction before removing the breast to prevent any potential damage to the nipple and promote a smooth breastfeeding experience for both the mother and the baby. This technique is commonly recommended in breastfeeding education to ensure proper latch and prevent nipple trauma.
The nurse is teaching a prenatal class about breast changes during pregnancy. Which change is expected?
- A. Decrease in nipple pigmentation.
- B. Reduction in breast size.
- C. Darkening of the areola.
- D. Development of inverted nipples.
Correct Answer: C
Rationale: Darkening of the areola is a common change due to hormonal influences during pregnancy.