Nokea
The nurse correctly explains to the group that the discomfort associated with varicose veins is relieved by which activity?
- A. Resting with the feet in a dependent position
- B. Sitting for periods of time when possible
- C. Putting on calf-length, elastic-top hose
- D. Moving around after standing in one position
Correct Answer: C
Rationale: Elastic-top hose improves venous return, reducing discomfort from varicose veins, unlike dependent positioning or sitting.
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The nurse is caring for the pregnant client at 20 weeks’ gestation. At what level should the nurse expect to palpate the client’s uterine height?
- A. Two finger-breadths above the symphysis pubis
- B. Halfway between the symphysis pubis and the umbilicus
- C. At the level of the umbilicus
- D. Two finger-breadths above the umbilicus
Correct Answer: C
Rationale: At 20 gestational weeks, the uterus should be at the level of the umbilicus. The uterine height is too low for 20 weeks’ gestation. At 13 weeks, the uterus would be approximately two finger-breadths above the symphysis pubis. The uterine height is too low for 20 weeks’ gestation. At 16 weeks, the uterus would be approximately halfway between the umbilicus and symphysis pubis. The uterine height is too high for 20 weeks’ gestation. At 22 weeks, the uterus would be two finger-breadths above the umbilicus.
Which instruction supports breastfeeding success in the postpartum period?
- A. Position the baby to latch correctly
- B. Feed only when the baby cries
- C. Limit feeding to every 4 hours
- D. Supplement with formula immediately
Correct Answer: A
Rationale: Correct latch positioning ensures effective breastfeeding, promoting milk supply and preventing nipple pain.
The 29-weeks-pregnant client presents to triage with decreased fetal movement. Her initial BP is 140/90 mm Hg. She states she “doesn’t feel well” and her vision is “blurry.” Additional assessment findings include: normal reflexes, +2 proteinuria, trace pedal edema, and puffy face and hands. What is the most important information that the nurse should obtain from the client’s prenatal record?
- A. Depressed liver enzymes
- B. BP at her first prenatal visit
- C. Urine dipstick from last visit
- D. The pattern of weight gain
Correct Answer: B
Rationale: The pregnant client with a BP that is greater than 140/90 mm Hg with the presence of proteinuria may have preeclampsia. New-onset hypertension is associated with preeclampsia. Generalized vasospasm in preeclampsia would result in reduced blood flow to the liver and elevated, not depressed, liver enzymes. The urine dip from the last visit should be reviewed but is not the most important to review because the significant information is the client’s elevated BP. The weight gain pattern should be reviewed but is not the most important to review because the significant information is the client’s elevated BP.
The client in labor is requesting water therapy (hydrotherapy) to help provide pain relief and relaxation. Her recent vaginal exam was 2/50/—2. How should the nurse respond to the client’s request?
- A. “Usually we initiate hydrotherapy during active labor.”
- B. “You will not need to change positions quite as much.”
- C. “We will not be able to monitor fetal heart rate as easily.”
- D. “You can use hydrotherapy for up to 60 minutes at a time.”
Correct Answer: A
Rationale: Hydrotherapy is usually initiated when the client is in active labor, at approximately 4 or 5 cm. This timing will help reduce the risk of prolonged labor and provide a welcome change when the contractions are becoming stronger and closer together. Changing position takes less effort while immersed in water, so women are encouraged to change positions more frequently to help facilitate the process of labor. FHR monitoring can be done just as easily during hydrotherapy, using a wireless external monitor, Doppler, or fetoscope. Internal electrodes can be placed during most types of hydrotherapy but is contraindicated during jet hydrotherapy. There is no time limit for laboring women to use hydrotherapy; they may stay as long as desired, unless complications develop during the labor process.
If this nurse is similar to other women experiencing fatigue, which suggestions for decreasing fatigue should be implemented? Select all that apply.
- A. Use break and lunch periods for resting.
- B. Void every 2 hours.
- C. Eat foods high in carbohydrates.
- D. Schedule work days close together.
- E. Refrain from working overtime.
- F. Get at least 12 hours of sleep per night.
Correct Answer: A,E
Rationale: Resting during breaks and avoiding overtime reduce fatigue; 12 hours of sleep is excessive, and voiding or carbs do not directly address fatigue.