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The nurse is instructing a pregnant client regarding measures to prevent a recurrent episode of preterm labor. Which statement by the client indicates the need for further teaching?
- A. I will report any feeling of pelvic pressure.
- B. I will not engage in sexual intercourse at this time.
- C. I will adhere to the limitations in activity and stay off my feet.
- D. I will limit my fluid intake to three 8-ounce glasses of fluid per day.
Correct Answer: D
Rationale: Risks for preterm labor include dehydration. A client should not restrict fluids (except for those containing alcohol and caffeine). A sign of preterm labor may be pelvic pressure without the perception of a contraction. Mechanical stimulation of the cervix during intercourse can stimulate contractions. A decrease in activity and bed rest are often prescribed in an attempt to decrease pressure on the cervix and to increase uterine blood flow.
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The nurse is teaching a client the proper technique for using a cane. Which statements should the nurse include in the teaching? Select all that apply.
- A. Hold the cane on the affected side.
- B. Hold the cane on the unaffected side.
- C. Move the cane at the same time as the affected leg.
- D. Move the cane at the same time as the unaffected leg.
- E. Hold the cane 8 to 10 inches from the side of the foot.
Correct Answer: B,C
Rationale: The cane is held on the unaffected side and moved with the affected leg to provide support. The cane is held closer to the body, not 8-10 inches away.
A postpartum nurse has instructed a new mother regarding how to bathe her newborn. The nurse demonstrates the procedure to the mother and, on the following day, asks the mother to perform the procedure. Which observation by the nurse indicates that the mother is performing the procedure correctly?
- A. The mother cleans the ears and then moves to the eyes and the face.
- B. The mother begins to wash the newborn infant by starting with the eyes and face.
- C. The mother washes the arms, chest, and back followed by the neck, arms, and face.
- D. The mother washes the entire newborn infant's body and then washes the eyes, face, and scalp.
Correct Answer: B
Rationale: Bathing should start at the eyes and face and with the cleanest area first. Next, the external ears and behind the ears are cleaned. The newborn infant's neck should be washed because formula, lint, and breast milk will often accumulate in the folds of the neck. The hands and arms are then washed. The newborn infant's legs are washed next, with the diaper area being washed last.
The nurse has completed giving medication instructions to a client receiving benazepril to treat hypertension. Which statement made by the client indicates to the nurse that the client needs further teaching?
- A. I need to change positions slowly.
- B. I need to monitor my blood pressure every week.
- C. I need to use salt moderately in cooking and on foods.
- D. I need to report signs and symptoms of infection to my doctor.
Correct Answer: D
Rationale: Benazepril is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension. Client education includes changing positions slowly to avoid orthostatic hypotension, monitoring blood pressure regularly, and using salt moderately as part of a heart-healthy diet. However, reporting signs and symptoms of infection is not directly related to benazepril use, as infections are not a common side effect. The client may need further teaching to clarify the specific side effects to monitor, such as cough, swelling, or signs of hyperkalemia.
A child is seen in the health care clinic, and testing for human immunodeficiency virus (HIV) is performed because of the child's exposure to HIV infection. Which home care instruction should the nurse provide to the parents of the child?
- A. Avoid sharing toothbrushes.
- B. Avoid all immunizations until the diagnosis is established.
- C. Wipe up any blood spills with a rag, and allow them to air-dry.
- D. Wash your hands with half-strength bleach if they come in contact with the child's blood.
Correct Answer: A
Rationale: Parents should avoid sharing toothbrushes to prevent potential HIV transmission through blood or bodily fluids. Immunizations should be kept up to date to protect the child. Blood spills should be cleaned with a paper towel, followed by soap and water, then a bleach solution, not just a rag and air-drying. Washing hands with soap and water is sufficient; bleach is too caustic for skin.
The nurse has completed teaching with a hemodialysis client regarding the self-monitoring of the fluid status between hemodialysis treatments. The nurse determines that the client understands the information given if the client states the need to record which item(s) on a daily basis?
- A. Activity
- B. Pulse and respiratory rate
- C. Intake, output, and weight
- D. Blood urea nitrogen and creatinine levels
Correct Answer: C
Rationale: Recording daily intake, output, and weight helps monitor fluid status, ensuring no more than 0.5 kg weight gain per day between hemodialysis sessions. Activity, pulse, respiratory rate, and lab values are not daily client responsibilities.