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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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.
Which nursing instructions concerning exercise during pregnancy are accurate? Select all that apply.
- A. Avoid exercising during hot, humid weather.
- B. Avoid exercises involving bouncing or jumping movements.
- C. Drink plenty of fluids before and after exercising.
- D. Limit strenuous activity to no more than 60 minutes a session.
- E. Perform exercises only in the supine position.
- F. Limit exercising to once per week.
Correct Answer: A,B,C
Rationale: Exercising in hot weather risks overheating, bouncing movements may strain joints, and hydration is crucial. Supine exercises are avoided late in pregnancy.
While assessing the postpartum client who is 10 hours post—vaginal delivery, the nurse notes a perineal pad that is totally saturated. To determine the significance of this finding, which question should the nurse ask the client first?
- A. “How often are you experiencing uterine cramping?”
- B. “When was the last time you changed your peri-pad?”
- C. “Are you having any bladder urgency or frequency?”
- D. “Did you pass clots that required changing your peri-pad?”
Correct Answer: B
Rationale: Once the nurse has determined the length of time the pad has been in place, the nurse could decide if asking about uterine cramping is appropriate. The amount of lochia on a perineal pad is influenced by the individual client’s pad changing practices. Thus, the nurse should ask about the length of time the current pad has been in place before making a judgment about whether the amount is concerning. Although bladder incontinence could cause pad saturation, it is more important to ask about the length of time the pad has been in place. Based on the client’s answer, the nurse could decide if asking about bladder urgency or frequency needs further assessment. Passing clots may require more frequent pad change, but first the nurse should determine if the reason for the saturated pad is the length of time it has been in place.
The client, who is 20 days postpartum, telephones the perinatal clinic to tell the nurse that she is having heavy, bright red bleeding since hospital discharge 18 days ago. Which instruction to the client is correct?
- A. “You need to come to the clinic immediately.”
- B. “Decrease physical activity until the bleeding stops.”
- C. “There is no need for concern; this is expected after birth.”
- D. “Call next week if the bleeding has not stopped by then.”
Correct Answer: A
Rationale: Lochia rubra that persists for longer than 2 weeks is suggestive of subinvolution of the uterus, which is the most common cause of delayed postpartum hemorrhage. The client should be seen in the clinic immediately to determine what is causing her abnormal lochial discharge. Increased physical activity can lead to increased lochial discharge, but the client is reporting continuous lochia rubra, which is abnormal. Lochia rubra is expected to last for up to 3 days after birth, not 20 days. Waiting until next week to be seen only delays determining the cause for her abnormal bleeding and increases the risk of the client for other complications.