Nokea
The nurse is educating a client about postpartum depression. What statement indicates understanding?
- A. It's normal to feel sad for the first 6 months postpartum.
- B. I should seek help if I have trouble bonding with my baby.
- C. Postpartum depression only occurs in first-time mothers.
- D. I should ignore feelings of hopelessness—they will pass.
Correct Answer: B
Rationale: Difficulty bonding with the baby can be a sign of postpartum depression and should be addressed.
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A neonate is being discharged home with a fiber-optic blanket for treatment of physiologic jaundice. What is important for the nurse to include in the discharge instructions?
- A. Cover the infant's eyes during the treatment.
- B. Reduce the daily number of formula feedings.
- C. Encourage frequent feeding to increase intake.
- D. Expect a constipated stool until jaundice clears.
Correct Answer: C
Rationale: Frequent feeding aids in bilirubin excretion.
The nurse is teaching a prenatal class about warning signs in pregnancy. Which symptom should be reported immediately?
- A. Mild swelling in the feet.
- B. Headache unrelieved by rest or medication.
- C. Increased appetite.
- D. Frequent urination.
Correct Answer: B
Rationale: A headache unrelieved by rest or medication may indicate preeclampsia or other serious conditions and should be reported immediately.
A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 min and a frequency of 3 min. The nurse obtains the following vital signs: fetal heart rate 130/min, maternal heart rate 128/min and maternal blood pressure 92/54 mm Hg. Which of the following is the priority action for the nurse to take?
- A. Notify the provider of the findings.
- B. Position the client with one hip elevated.
- C. Ask the client if she needs pain medication.
- D. Have the client void.
Correct Answer: A
Rationale: The priority action for the nurse in this situation is to notify the provider of the vital signs and the client's condition. The maternal blood pressure of 92/54 mm Hg is low, which can indicate hypotension. Hypotension during labor can lead to decreased perfusion to both the mother and baby, potentially causing harm. Therefore, the provider needs to be notified promptly so that appropriate interventions can be initiated to address the maternal hypotension and ensure the well-being of both the mother and the baby. Positioning the client with one hip elevated, asking about pain medication, and having the client void can be important interventions, but they are not the priority in this situation where maternal hypotension is a concern.
What is essential for the nurse to teach a woman who has just had an intrauterine device (IUD) inserted?
- A. Palpate her lower abdomen each month to check the patency of the device.
- B. Remain on bed rest for 24 hours after insertion of the device.
- C. Report any complaints of painful intercourse to the physician.
- D. Insert spermicidal jelly within 4 hours of every sexual encounter.
Correct Answer: C
Rationale: Painful intercourse may indicate IUD displacement or complications.
The nurse is functioning in the primary role to care for a 12-year-old boy with metastatic cancer in the liver. Which activity is typical of advocacy?
- A. Instructing parents about proper home care
- B. Educating the family about choices they have
- C. Telling parents about clinical guidelines
- D. Teaching the family about types of cancers
Correct Answer: B
Rationale: Educating the family about choices they have regarding therapies for the cancer in the child's liver is an example of advocacy, in which the nurse advances the interests of the child and family by informing them of options and assisting them to make informed decisions.