Nokea
Which advice can the nurse give to relieve the client's backache? Select all that apply.
- A. Avoid clothing that fits tightly around the waist.
- B. Sleep on a heating pad.
- C. Take a nonopioid pain reliever regularly.
- D. Wear low-heeled shoes.
- E. Carry objects close to your body.
- F. Squat when picking objects off the floor.
Correct Answer: A,D,E,F
Rationale: Tight clothing, high heels, and improper lifting exacerbate backaches; low-heeled shoes, proper lifting, and loose clothing help relieve strain.
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The client is diagnosed with moderate postpartum depression (PPD) after vaginal delivery of a 10 lb baby. One week following the delivery, the nurse is completing a home visit. Which finding should be the nurse’s priority?
- A. Lochia has a foul-smelling odor.
- B. Small but tender hemorrhoids.
- C. Yells at her baby to stop crying.
- D. Client cries throughout the visit.
Correct Answer: C
Rationale: Lochia that is foul smelling could indicate that the client has a postpartum infection. The client needs to be seen by an HCP, but the safety of the infant is priority. The presence of tender hemorrhoids may be uncomfortable and should be addressed, but this is not priority. It is inappropriate for the client to yell at her baby to stop crying. Verbal abuse can escalate to physical abuse. The safety of the infant should be the nurse’s priority. Persistent crying is a sign of PPD and would be expected. However, persistent crying should be further explored because treatment may be ineffective.
The client is hospitalized at 30 weeks’ gestation in preterm labor. A test is performed to determine the lecithin to sphingomyelin (L/S) ratio, with results indicating a ratio less than 2:1. The nurse planning care for the client should expect to implement which interventions? Select all that apply.
- A. Administering hydralazine
- B. Maintaining the client on bedrest
- C. Preparing the client for a nonstress test
- D. Giving betamethasone
- E. Administering metronidazole
Correct Answer: B,C,D
Rationale: Bed rest will maximize placental oxygenation while fetal lung maturity continues. The client should be prepared for a nonstress test. This is used to monitor for uterine contractions and labor. Labor needs to be stopped until the fetal lungs are more fully developed. Betamethasone (Celestone Soluspan) is a corticosteroid and is given to stimulate fetal lung maturity. Hydralazine (Apresoline) is an antihypertensive agent and is administered to clients experiencing preeclampsia, not preterm labor. Metronidazole (Flagyl) is an antiprotozoal and antibacterial agent used to treat a vaginal infection; there is no indication that the client has a vaginal infection.
The nurse’s laboring client is being electronically monitored during her labor. The baseline FHR throughout the labor has been in the 130s. In the last 2 hours, the baseline has decreased to the 100s. How should the nurse document this FHR?
- A. Tachycardia
- B. Bradycardia
- C. Late deceleration
- D. Within normal limits
Correct Answer: B
Rationale: An FHR baseline less than 110 is classified as bradycardia. Tachycardia occurs when the baseline is greater than 160 bpm. A prolonged deceleration is defined as a change from the baseline FHR that occurs for 2 to 10 minutes before returning to baseline. A late deceleration is a gradual decrease and return of the FHR to baseline, associated with a uterine contraction. A decrease to the 100s is not within the normal range. The normal FHR is 120 to 160 bpm.
The client, who had preeclampsia and delivered vaginally 4 hours ago, is still receiving magnesium sulfate IV. When assessing the client’s deep tendon reflexes (DTRs), the nurse finds that they are both weak, at 1+, whereas previously they were 2+ and 3+. Which actions should the nurse plan? Select all that apply.
- A. Notify the client’s HCP about the reduced DTRs.
- B. Prepare to increase the magnesium sulfate dose.
- C. Prepare to administer calcium gluconate IV.
- D. Assess the level of consciousness and vital signs.
- E. Ask the HCP about drawing a serum calcium level.
Correct Answer: A,C,D
Rationale: The HCP should be notified about the decreased DTRs because weakening of these may indicate magnesium sulfate toxicity. Increasing the magnesium sulfate dose would worsen the situation and could lead to a depressed respiratory rate. Any time the client is receiving a magnesium sulfate infusion, the nurse should be prepared for the possibility of needing the antidote, calcium gluconate. The nurse should assess the client’s vital signs and level of consciousness, as decreased level of consciousness and respiratory effort are serious side effects of magnesium sulfate. The nurse should ask the HCP about drawing a serum magnesium level (not a serum calcium level) to determine whether the client is experiencing magnesium toxicity.
The nurse identifies which sign as indicative of postpartum depression?
- A. Occasional mood swings
- B. Persistent feelings of hopelessness
- C. Excitement about motherhood
- D. Increased energy levels
Correct Answer: B
Rationale: Persistent feelings of hopelessness are a key indicator of postpartum depression, requiring intervention.