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The nurse is teaching the client about postpartum depression. The nurse should encourage the client to----------------- and ----------------- to help prevent postpartum depression.
- A. Engage in regular physical activity
- B. Maintain a strong support system
- C. Get adequate rest and sleep
- D. Eat a well-balanced diet
- E. exercise 30 min per day
Correct Answer: B,E
Rationale: The correct answers are B and E. Maintaining a strong support system is crucial in preventing postpartum depression as it provides emotional support. Exercise for 30 minutes per day can help release endorphins, reduce stress, and improve mood. Engaging in regular physical activity (choice A) is beneficial but not as specific as the 30-minute exercise recommendation. Getting adequate rest and sleep (choice C) is important but may not solely prevent postpartum depression. Eating a well-balanced diet (choice D) is essential for overall health but does not directly address the prevention of postpartum depression.
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A nurse is caring for a client who reports spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and notices that the umbilical cord is protruding. After calling for assistance and notifying the provider, which of the following actions should the nurse take next?
- A. Perform a vaginal examination by applying upward pressure on the presenting part.
- B. Cover the umbilical cord with a sterile saline-saturated towel.
- C. Administer oxygen via nonrebreather mask at 8 L/min.
- D. Initiate an infusion of IV fluids for the client.
Correct Answer: B
Rationale: The correct answer is B: Cover the umbilical cord with a sterile saline-saturated towel. This action is important to prevent compression of the umbilical cord, which can lead to decreased blood flow to the fetus resulting in fetal distress or demise. By covering the protruding cord with a sterile saline-saturated towel, the nurse can protect the cord and maintain adequate blood flow until further interventions can be performed by the healthcare team. Performing a vaginal examination by applying upward pressure on the presenting part (choice A) can further compress the cord and worsen the situation. Administering oxygen via nonrebreather mask (choice C) and initiating an infusion of IV fluids (choice D) are important interventions but should be done after addressing the umbilical cord protrusion to ensure adequate oxygenation and perfusion to the fetus.
A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client into a hands-and-knees position. Which of the following questions should the nurse ask to evaluate the effectiveness of this intervention?
- A. Does that lessen your suprapubic pain?
- B. Are you feeling relief from your pelvic pressure?
- C. Do your contractions feel further apart?
- D. Has your back labor improved?
Correct Answer: D
Rationale: The correct answer is D: "Has your back labor improved?" In the occipitoposterior position, the baby's head is pressing against the mother's back, causing intense back pain. Placing the client in a hands-and-knees position can help alleviate this discomfort by encouraging the baby to rotate into a more favorable position. By asking if the back labor has improved, the nurse can directly assess the effectiveness of the intervention.
Incorrect choices:
A: "Does that lessen your suprapubic pain?" - This question is not directly related to the occipitoposterior position or the hands-and-knees intervention.
B: "Are you feeling relief from your pelvic pressure?" - While pelvic pressure may be present, the primary concern with the occipitoposterior position is back labor.
C: "Do your contractions feel further apart?" - Contractions may not necessarily change in frequency with a change in position, especially in cases of fetal malposition.
Which of the following assessment findings requires Immediate follow-up? Select all that apply,
- A. Platelet count
- B. Vaginal bleeding
- C. HCT
- D. RBC Count
- E. Fetal heart rate
- F. hgb
- G. WBC Count
Correct Answer: B,C,E,F
Rationale: The correct answers are B, C, E, and F. Vaginal bleeding requires immediate follow-up to assess for potential complications. HCT, HGB, and WBC count are crucial for evaluating maternal health. Fetal heart rate is essential for monitoring fetal well-being. Platelet count and RBC count are important but not as urgent as the other findings.
A nurse is assessing a client who is at 6 weeks of gestation and adheres to a vegan diet. Which of the following questions should the nurse ask to assess the client’s dietary intake?
- A. How much protein do you eat in a day?
- B. Are you taking a Vitamin C supplement?
- C. Have you considered eating shellfish?
- D. When was the last time you ate meat?
Correct Answer: A
Rationale: The correct answer is A: "How much protein do you eat in a day?" This question is important because a vegan diet may lack sufficient protein, crucial for fetal development at 6 weeks gestation. Protein is essential for cell growth and repair. Choice B is incorrect as Vitamin C is abundant in plant-based foods. Choice C is incorrect because shellfish are not part of a vegan diet. Choice D is incorrect because consuming meat contradicts a vegan diet.
A nurse is providing teaching to the parents of a newborn about the Plastibell circumcision technique. Which of the following information should the nurse include?
- A. The Plastibell will be removed 4 hours after the procedure.
- B. Make sure the newborn’s diaper is snug.
- C. Yellow exudate will form at the surgical site in 24 hours.
- D. Notify the provider if the end of your baby’s penis appears dark red.
Correct Answer: D
Rationale: The correct answer is D: Notify the provider if the end of your baby’s penis appears dark red. This is important to monitor for signs of infection, such as redness, swelling, or discharge. Yellow exudate forming in 24 hours (C) is incorrect as it may indicate infection. The Plastibell is typically removed after a few days, not 4 hours (A). Ensuring a snug diaper (B) is irrelevant to the circumcision technique.