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A nurse is caring for a client who had a vaginal delivery 4 hr ago and reports perineal pain of 6 on a scale of 0 to 10.
Which of the following actions should the nurse take?
- A. Offer an ice pack to the client during the first 24 hr.
- B. Apply a corticosteroid cream to the perineal area twice daily.
- C. Increase the client's fluid intake for 48 hr.
- D. Catheterize the client's bladder.
Correct Answer: A
Rationale: Offering an ice pack reduces inflammation and numbs the perineal area, providing effective pain relief in the immediate postpartum period after vaginal delivery.
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A nurse is reinforcing teaching with a client about common discomforts during the first trimester of pregnancy. Which of the following discomforts should the nurse include in the teaching?
- A. Urination urgency and frequency
- B. Tingling in the fingers
- C. Round ligament pain
- D. Perineal discomfort and pressure
Correct Answer: A
Rationale: Increased urgency and frequency of urination are common discomforts during the first trimester of pregnancy. This occurs due to hormonal changes and the growing uterus pressing on the bladder, which reduces its capacity.
A nurse is assisting with the admission of a client who has hyperemesis gravidarum.
Which of the following laboratory tests is the priority to complete?
- A. Serum bilirubin
- B. Liver enzymes
- C. Urinalysis for ketones
- D. CBC
Correct Answer: C
Rationale: Urinalysis for ketones is the priority to assess dehydration and ketosis from severe vomiting in hyperemesis gravidarum, guiding immediate treatment to prevent complications.
A nurse is caring for a client who is at 9 weeks of gestation and reports nausea in the morning that continues until midafternoon.
Which of the following actions should the nurse encourage the client to take?
- A. Restrict fluids to 1,000 mL/day.
- B. Take an over-the-counter antacid
- C. Increase intake of fresh fruits
- D. Eat dry, bland foods in the morning
Correct Answer: D
Rationale: Encouraging the client to eat dry, bland foods in the morning, like crackers or toast, can help alleviate nausea associated with morning sickness by settling the stomach, making it an effective strategy.
A nurse is contributing to the plan of care for a client who is postpartum and has mastitis.
Which of the following actions should the nurse plan to take?
- A. Prepare the client for an abdominal sonogram.
- B. Encourage the client to continue to breastfeed
- C. Encourage the client to wear a bra that is loose fitting
- D. Limit the client's daily fluid intake.
Correct Answer: B
Rationale: Continuing to breastfeed is recommended for clients with mastitis. Breastfeeding helps to drain the breast and can speed up recovery. It also helps to prevent complications such as breast abscess and supports continued milk production.
A nurse is reinforcing teaching about preterm labor with a client who is at 28 weeks of gestation.
Which of the following statements by the client indicates an understanding of the teaching?
- A. I have contractions more often than every 10 minutes, might be in preterm labor.
- B. I can take a daily iron supplement to prevent preterm labor.
- C. I should expect to feel pain in my upper right abdomen if I'm having preterm labor.
- D. I might be experiencing preterm labor if walking stops my contractions.
Correct Answer: A
Rationale: Contractions occurring more frequently than every 10 minutes can be a sign of preterm labor and should prompt the client to seek medical attention, indicating an accurate understanding of preterm labor warning signs.