Nokea
When teaching the class about varicose veins, which symptom should the nurse instruct clients to report immediately?
- A. The appearance of additional varicose veins
- B. Varicose veins that are purple in color
- C. Legs that begin to ache and feel heavy
- D. Calves that become red, tender, and warm
Correct Answer: D
Rationale: Red, tender, warm calves may indicate deep vein thrombosis, a serious condition requiring immediate reporting.
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The 38-year-old pregnant client at 22 weeks’ gestation has just been told she has hydramnios after undergoing a sonogram for size greater than dates. The nurse should further assess for which conditions associated with hydramnios? Select all that apply.
- A. A congenital anomaly
- B. Gestational diabetes
- C. Chronic hypertension
- D. TORCH infections
- E. Preeclampsia
Correct Answer: A,B,D
Rationale: In cases of anencephaly, the fetus is thought to urinate excessively because of overstimulation of the cerebrospinal centers, resulting in hydramnios. The nurse should further assess for gestational diabetes. Hydramnios is thought to occur from excessive fetal urination due to fetal hyperglycemia. Infants with mothers infected with toxoplasmosis, rubella, CMV, or herpes simplex virus infections (TORCH) are more likely to have hydramnios due to the inflammatory response and fluid accumulation. Chronic hypertension is not associated with excess amniotic fluid. Preeclampsia is not associated with excess amniotic fluid.
The clinic nurse reviews the laboratory results illustrated from the postpartum client who is 3 days postdelivery. What should the nurse do in response to these results?
- A. Document the laboratory report findings
- B. Assess the client for increased lochia
- C. Assess the client’s temperature orally
- D. Notify the health care provider immediately
Correct Answer: A
Rationale: The only action required is to document the findings; all values are within expected parameters. Nonpathological leukocytosis often occurs during labor and in the immediate postpartum period because labor produces a mild pro-inflammatory state. WBCs should return to normal by the end of the first postpartum week. Hct and Hgb will begin to decrease on postpartum day 3 or 4 from hemodilution. Assessing the client’s lochia is unnecessary with these results. Assessing the client’s temperature is unnecessary with these results. Notifying the HCP is unnecessary with these results.
When providing information about iron supplements, which instruction by the nurse is most appropriate?
- A. Take the supplement with meals.
- B. Take the supplement with orange juice.
- C. Increase your intake of dairy products.
- D. You can substitute dietary sources of iron for this medication.
Correct Answer: B
Rationale: Taking iron with orange juice (rich in vitamin C) enhances absorption, addressing the client's constipation concern.
The nurse is reviewing laboratory results of the client in labor prior to her receiving epidural anesthesia. Which result is most important to report to the HCP prior to the initiation of the epidural?
- A. White blood cells: 24,000/mm3
- B. Glucose: 78 grams/dL
- C. Hemoglobin: 10.2 g/dL
- D. Platelets: 100,000/mm3
Correct Answer: D
Rationale: The nurse should report the low platelet count of 100,000/mm3 (normal is 150,000 to 450,000/mm3). A low count can contribute to bleeding and affect the use of epidural anesthesia. The WBC count in labor is normally increased due to the stress of labor and can be as high as 25,000/mm3 to 30,000/mm3. The glucose level normally falls during labor because of an expenditure of energy in labor. Anemia or a reduction in the Hgb and Hct is common in pregnancy. Hgb levels less than 10 g/dL are considered abnormal in pregnancy.
The nurse advises the client to keep the newborn's crib free of which item?
- A. Soft toys and blankets
- B. Firm mattress
- C. Fitted sheet
- D. Crib bumpers
Correct Answer: A
Rationale: Soft toys and blankets in the crib increase the risk of suffocation and SIDS, and should be avoided.