Nokea
The nurse provides information to a preoperative client who will be receiving relaxation therapy. What effects should the nurse teach the client to expect regarding this type of therapy? Select all that apply.
- A. Increased heart rate
- B. Improved well-being
- C. Lowered blood pressure
- D. Increased respiratory rate
- E. Decreased muscle tension
- F. Increased neural impulses to the brain
Correct Answer: B,C,E
Rationale: Relaxation is the state of generalized decreased cognitive, physiological, and/or behavioral arousal. Relaxation elongates the muscle fibers, reduces the neural impulses to the brain, and thus decreases the activity of the brain and other systems. The effects of relaxation therapy include improved well-being; lowered blood pressure, heart rate, and respiratory rate; decreased muscle tension; and reduced symptoms of distress in persons who need to undergo treatments, those experiencing complications from medical treatment or disease, or those grieving the loss of a significant other. This therapy does not cause an increased heart rate, increased respiratory rate, or increased neural impulses to the brain.
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A clinic nurse is assessing a prenatal client who has been diagnosed with heart disease. The nurse carefully assesses the client's vital signs, weight, and fluid and nutritional status to detect for complications caused by which pregnancy-related concern?
- A. Rh incompatibility
- B. Fetal cardiomegaly
- C. The increase in circulating blood volume
- D. Hypertrophy and increased contractility of the heart
Correct Answer: C
Rationale: Pregnancy taxes the circulating system of every woman because the blood volume increases, which causes the cardiac output to increase. Stroke volume × heart rate = cardiac output (SV × HR = CO). Options 1, 2, and 4 are not directly associated with pregnancy in a client with a cardiac condition.
The hemoglobin levels of a client in her first trimester of pregnancy are indicative of iron deficiency anemia. Which assessment findings support the diagnosis of this type of anemia? Select all that apply.
- A. Yellowish sclera
- B. Reports of severe fatigue
- C. Pink mucous membranes
- D. Increased vaginal secretions
- E. Reports of frequent headaches
- F. Reports of increased frequency of voiding
Correct Answer: B,E
Rationale: Iron deficiency anemia is described as a hemoglobin blood concentration of less than 10.5 to 11.0 g/dL (105 to 110 mmol/L). Complaints of headaches and severe fatigue are abnormal findings and may reflect complications of this type of anemia caused by the decreased oxygen supply to vital organs. Options 3, 4, and 6 are normal findings in the first trimester of pregnancy. Yellow sclera (whites of the eyes) is associated with jaundice.
The nurse is preparing to administer an opioid to a client via an epidural catheter. Before administering the medication, the nurse aspirates and obtains 5 mL of clear fluid. Based on this finding, which action should the nurse take?
- A. Inject the opioid slowly.
- B. Notify the anesthesiologist.
- C. Inject the aspirate back into the catheter and administer the opioid.
- D. Flush the catheter with 6 mL of sterile water before injecting the opioid.
Correct Answer: B
Rationale: Aspiration of clear fluid of less than 1 mL is indicative of epidural catheter placement. More than 1 mL of clear fluid or bloody return means that the catheter may be in the subarachnoid space or a vessel. Therefore, the nurse would not inject the medication and would notify the anesthesiologist. Options 1, 3, and 4 are incorrect actions.
A postpartum nurse caring for a client who delivered vaginally 2 hours ago palpates the fundus and notes the character of the lochia. Which characteristic of the lochia should indicate to the nurse that the client's recovery is normal?
- A. Pink-colored lochia
- B. White-colored lochia
- C. Serosanguineous lochia
- D. Dark red-colored lochia
Correct Answer: D
Rationale: When checking the perineum, the lochia is monitored for amount, color, and the presence of clots. The color of the lochia during the fourth stage of labor (the first 1 to 4 hours after birth) is dark red. Options 1, 2, and 3 are not the expected characteristics of lochia at this time period.
The nurse in the postpartum unit is assessing for signs of breast-feeding problems demonstrated by either the newborn or the mother. Which findings indicate a problem? Select all that apply.
- A. The infant exhibits dimpling of the cheeks.
- B. The infant makes smacking or clicking sounds.
- C. The mother's breast gets softer during a feeding.
- D. Milk drips from the mother's breast occasionally.
- E. The infant falls asleep after feeding less than 5 minutes.
- F. The infant can be heard swallowing frequently during a feeding.
Correct Answer: A,B,E
Rationale: Infant signs of breast-feeding problems include dimpling of the cheeks; making smacking or clicking sounds; falling asleep after feeding less than 5 minutes; refusing to breast-feed; tongue thrusting; failing to open the mouth at latch-on; turning the lower lip in; making short, choppy motions of the jaw; and not swallowing audibly. Softening of the breast during feeding, noting milk in the infant's mouth or dripping from the mother's breast occasionally, and hearing the infant swallow are signs that the infant is receiving adequate nutrition.