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The nurse is collecting data from a client who had a cesarean birth 12 hours ago. The client is restless, has a heart rate of 115/min, and is reporting dyspnea and anxiety. It would be a priority for the nurse to
- A. obtain a pulse oximetry reading for the client
- B. offer the client medication prescribed PRN for pain
- C. check the client's lower extremities for warmth and redness
- D. encourage guided imagery and breathing techniques for relaxation
Correct Answer: A
Rationale: Restlessness, tachycardia, dyspnea, and anxiety post-cesarean suggest pulmonary embolism, a common postpartum complication. Pulse oximetry assesses oxygenation urgently. Pain, DVT, or anxiety are less immediate concerns.
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The nurse is reinforcing education to a group of clients who are pregnant or planning pregnancy. Which of the following client statements about alcohol use in pregnancy indicate a need for further education? Select all that apply.
- A. As long as I don't binge drink, an occasional glass of wine is fine.
- B. I drank alcohol heavily before realizing I was pregnant, so there is no benefit to quitting now.
- C. If I drink alcohol, my baby may have withdrawal after birth but no permanent damage.
- D. It is important to stop drinking while I am trying to conceive.
- E. Third-trimester alcohol use is less harmful because the baby is fully developed.
Correct Answer: A,B,C,E
Rationale: No amount of alcohol is safe during pregnancy, as it can cause fetal alcohol spectrum disorders. Quitting at any point reduces harm. Alcohol can cause permanent damage, not just withdrawal. Third-trimester exposure still risks brain development. Stopping preconception is correct.
A client calls the nurse with a complaint of sudden deep throbbing leg pain. What is the appropriate first action by the nurse?
- A. Suggest isometric exercises
- B. Maintain the client on bed rest
- C. Ambulate for several minutes
- D. Apply ice to the extremity
Correct Answer: B
Rationale: Maintain the client on bed rest. The finding suggests deep vein thrombosis. The client must be maintained on bed rest and the provider notified immediately.
The nurse is caring for a client with deep venous thrombosis of the lower extremity. Which of the following findings would the nurse expect to observe? Select all that apply.
- A. dry, shiny, hairless skin on the affected extremity
- B. warmth and redness of the affected extremity
- C. reports of pain in the affected calf
- D. edema of the affected extremity
- E. cyanosis of the affected toes
Correct Answer: B,C,D
Rationale: DVT causes inflammation, leading to warmth, redness, pain, and edema in the affected extremity. Dry, shiny, hairless skin and cyanosis are more typical of arterial insufficiency, not DVT.
A nurse receives report on a group of clients. Which client should the nurse assess first?
- A. A preschool-age child with a harsh cough, expiratory wheezes, and mild intercostal retractions
- B. A toddler playing with small toys who appears in distress, has circumoral cyanosis, and cannot speak
- C. A toddler with a barking cough, infrequent inspiratory stridor, and oxygen saturation of 94% on room air
- D. An infant with an axillary temperature of 100.1 F (37.8 C) who is tugging at the left ear
Correct Answer: B
Rationale: The toddler with circumoral cyanosis, distress, and inability to speak suggests a potential airway obstruction, a life-threatening emergency requiring immediate assessment. Other clients show less acute symptoms.
A 6-month-old infant is being seen in the doctor's office. Which observation by the nurse should be brought to the physician's attention?
- A. The baby sits up but needs slight support.
- B. The baby was 7 lb at birth and now weighs 10 lb.
- C. The baby frequently drops objects and looks for them.
- D. The baby smacks her lips and drools.
Correct Answer: B
Rationale: A 6-month-old should double birth weight (14 lb expected for 7 lb); 10 lb suggests poor growth, requiring evaluation. Other findings are developmentally normal.