Nokea
The nurse is educating a client about postpartum care. What statement indicates the need for further teaching?
- A. I will call my doctor if I have a fever.
- B. It is normal to have heavy bleeding for two weeks.
- C. I will avoid lifting heavy objects.
- D. Breast tenderness is common when my milk comes in.
Correct Answer: B
Rationale: Heavy bleeding for two weeks is not normal and may indicate postpartum complications.
You may also like to solve these questions
An adolescent patient calls the office and asks to speak with the nurse. The patient cannot remember where she can place her contraceptive patch. What area of the body should the nurse tell her to avoid?
- A. breasts
- B. abdomen
- C. buttocks
- D. arm
Correct Answer: A
Rationale: The nurse should advise the adolescent patient to avoid placing the contraceptive patch on her breasts. The contraceptive patch is typically recommended to be placed on areas of the body with minimal hair and movement to ensure proper adherence and absorption of hormones. Placing the patch on the breasts may result in movement and friction, causing it to become dislodged or less effective. It is important to follow the specific instructions provided with the contraceptive patch on where to apply it for optimal effectiveness.
What is the primary nursing concern for a mother receiving magnesium sulfate therapy?
- A. Monitor blood pressure every 4 hours
- B. Monitor deep tendon reflexes hourly
- C. Assess respiratory rate and effort
- D. Prepare for delivery if signs of toxicity appear
Correct Answer: B
Rationale: Monitoring reflexes detects early signs of magnesium toxicity.
A nurse is caring for a client who is in the transition phase of labor and reports a pain level of 7 on a scale of 0 to Which of the following actions should the nurse take?
- A. Instruct the client to use effleurage
- B. Apply counter pressure to the client sacral.
- C. Assist the client with patterned-paced breathing.
- D. Teach the client the technique of biofeedback.
Correct Answer: B
Rationale: In the transition phase of labor, the contractions are intense and the client may experience significant discomfort and pain. Applying counter pressure to the client's sacral area can help alleviate this pain by providing some relief and support. Counter pressure involves applying firm pressure with the palms or fists to the lower back or sacral area during contractions. This technique can help to relieve some of the pressure and discomfort experienced during contractions, making it a beneficial action for the nurse to take in this situation.
The nurse is monitoring a pregnant client with severe preeclampsia. Which finding requires immediate intervention?
- A. Blood pressure of 140/90 mmHg.
- B. Urine output of 30 mL/hr.
- C. Complaints of headache and blurred vision.
- D. Weight gain of 1 pound in one week.
Correct Answer: C
Rationale: Headache and blurred vision are signs of worsening preeclampsia, indicating potential eclampsia.
The nurse suspects that a client has an early sign of ectopic
- B. Abdominal pain
- C. Vaginal spotting or light bleeding
- D. Pelvic pain
Correct Answer: C
Rationale: Vaginal spotting or light bleeding is one of the early signs of an ectopic pregnancy. Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, most commonly in the fallopian tube. The presence of vaginal spotting or light bleeding may indicate the implantation of the fertilized egg in a location other than the uterus, leading to the suspicion of an ectopic pregnancy. It is essential for the nurse to recognize this early sign and promptly assess the client for further evaluation and intervention to prevent complications such as rupture and severe bleeding that can be life-threatening.