Nokea
The nurse correctly assists the client into which position?
- A. Lithotomy
- B. Prone
- C. Sims'
- D. Trendelenburg's
Correct Answer: A
Rationale: The lithotomy position, with legs elevated and apart, is standard for pelvic examinations to provide access to the pelvic area.
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To best enhance absorption of the iron supplement, which foods should the nurse recommend the client increase in her diet? Select all that apply.
- A. Oranges
- B. Potatoes
- C. Bananas
- D. Broccoli
- E. Whole milk
- F. Carrots
Correct Answer: A,D
Rationale: Oranges and broccoli are rich in vitamin C, which enhances iron absorption, unlike the other options.
The postpartum client is being admitted for mastitis. The nurse should prepare the client for which interventions? Select all that apply.
- A. Walking at least four times in 24 hours
- B. Receiving a prescribed oral antibiotic
- C. Applying warm packs to the breasts
- D. Getting a prescribed anti-inflammatory drug
- E. Limiting oral fluid intake to 1000 mL per day
- F. Emptying the milk from her breasts frequently
Correct Answer: B,C,D,F
Rationale: Rest is important to promote healing. Bed rest may be initially prescribed for 24 hours. Treatment for mastitis includes administration of antibiotics to treat the infection. Application of warm packs decreases pain and promotes milk flow and breast emptying. Treatment for mastitis includes anti-inflammatory medications to treat fever and decrease breast inflammation. Increasing fluid intake to at least 2 to 3 liters is recommended, not limiting intake. If the breasts continue to be emptied by either breastfeeding or pumping, the duration of symptoms and the incidence of a breast abscess are decreased.
The client presents with vaginal bleeding at 7 weeks. Which action should be taken by the nurse first?
- A. Take the client’s vital signs
- B. Prepare examination equipment
- C. Give 2 liters oxygen per nasal cannula
- D. Assess the client’s response to the situation
Correct Answer: A
Rationale: Assessing the client’s VS should be completed first. Bleeding can cause hypotension. Although preparing examination equipment is important, the nurse should first focus on the client. Having oxygen available is important, but there is no indication that the client needs oxygen at this time. Assessing the client’s response is important, but assessment of physiological problems should occur first.
The nurse is caring for the pregnant client. Which assessment findings help the nurse determine that she may be in true labor? Select all that apply.
- A. Progressive cervical dilation and effacement
- B. Walking usually increases contraction intensity
- C. Warm tub baths and rest lessen contractions
- D. Discomfort is usually in the client’s abdomen
- E. Contractions increase in duration and intensity
Correct Answer: A,B,E
Rationale: Progressive cervical dilation and effacement indicate true labor. In false labor, the contractions may occur for several hours, but there is no cervical change. In true labor, walking usually increases the intensity of contractions. In false labor, walking usually has little or no effect on contractions and may sometimes decrease the frequency, intensity, and duration of contractions. Contractions increase in duration and intensity during true labor, while there is usually no change in contractions during false labor. Warm tub baths and rest lessen contractions during false labor. In true labor, contractions do not decrease with warm tub baths or rest. Discomfort is usually in the client’s abdomen during false labor. Discomfort begins in the back and radiates around to the abdomen during true labor.
The nurse advises the client to practice which technique to cope with labor pain?
- A. Lamaze breathing
- B. Holding her breath
- C. Tensing muscles
- D. Avoiding movement
Correct Answer: A
Rationale: Lamaze breathing helps manage labor pain by promoting relaxation and focus, unlike tensing or breath-holding.