Nokea
Which nursing instruction given to the client complaining about shortness of breath is most appropriate?
- A. Contact your health care provider immediately.
- B. Decrease your activity level to conserve oxygen.
- C. Ask your physician for a mild sedative.
- D. Sleep with your upper body elevated on pillows.
Correct Answer: D
Rationale: Sleeping with the upper body elevated reduces pressure on the diaphragm, easing shortness of breath.
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In the primigravid client, when is fetal movement typically felt for the first time?
- A. Between 10 and 14 weeks' gestation
- B. Between 16 and 20 weeks' gestation
- C. Between 22 and 26 weeks' gestation
- D. Between 28 and 32 weeks' gestation
Correct Answer: B
Rationale: Primigravid women typically feel fetal movement (quickening) between 16 and 20 weeks, later than multigravida women.
The nurse informs the pregnant client that her laboratory test indicates she has iron-deficiency anemia. Based on this diagnosis, the nurse should monitor this client for which problems? Select all that apply.
- A. Susceptibility to infection
- B. Easily fatigued
- C. Increased risk for preeclampsia
- D. Increased risk of diabetes
- E. Congenital defects
Correct Answer: A,B,C
Rationale: Iron-deficiency anemia is associated with susceptibility to infection because oxygen is not transported effectively. Iron-deficiency anemia is associated with fatigue because oxygen is not transported effectively. Iron-deficiency anemia is associated with risk of preeclampsia because oxygen is not transported effectively. Iron-deficiency anemia is not associated with an increased risk of diabetes. Iron-deficiency anemia is not associated with an increased risk of congenital defects.
The home care nurse is visiting the mother and her 6-day-old son. The nurse observes that the infant is sleeping in a crib on his back and has a blanket draped over his body. The mother had been sleeping in a nearby room. Which statements are appropriate for the nurse to make in response to this situation? Select all that apply.
- A. “I’m glad to see that you are sleeping while your baby sleeps.”
- B. “Having your baby sleep on his back reduces the risk of SIDS.”
- C. “It is best for you to sleep in the same room as your newborn.”
- D. “Position your baby on his tummy and side when he is awake.”
- E. “When using a blanket, always tuck its sides under the mattress.”
Correct Answer: A,B,D
Rationale: This is an appropriate statement. Sleeping while the infant sleeps will help the mother get the rest she needs. This is an appropriate statement. The American Academy of Pediatricians recommends the supine position for infant sleeping to decrease the risk of SIDS. The mother should be in close proximity and ready to respond when the infant wakes and/or cries, but she does not need to sleep in the same room as the infant. This is an appropriate statement. While awake the infant should be positioned prone and side-lying to help build neck muscles and decrease the chance of deformation plagiocephaly. Deformation plagiocephaly is a malformation of the skull caused by consistently lying on the back. A blanket, if used, should swaddle the infant rather than being draped over the infant. Swaddling helps prevent suffocation. Tucking the blanket sides under the mattress does not prevent suffocation.
The nurse teaches the client to monitor which newborn condition?
- A. Umbilical cord stump for infection
- B. Daily weight gain over 1 pound
- C. Frequent crying as abnormal
- D. No bowel movements for a week
Correct Answer: A
Rationale: Monitoring the umbilical cord stump for infection (redness, discharge) is critical for newborn health.
The nurse teaches the client to report which postpartum symptom immediately?
- A. Mild cramping
- B. Foul-smelling lochia
- C. Light vaginal bleeding
- D. Fatigue after delivery
Correct Answer: B
Rationale: Foul-smelling lochia may indicate infection, requiring immediate reporting to prevent complications.