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A nurse is reinforcing teaching with a newly licensed nurse concerning a client on a postpartum unit following a cesarean birth.
Which of the following measures should the nurse include in the instructions to prevent thrombophlebitis?
- A. Apply elastic stockings before the client gets out of bed
- B. Have the client ambulate as often as possible.
- C. Apply warm, moist packs to the client's lower legs
- D. Administer NSAIDs every 4 to 6 hr.
Correct Answer: B
Rationale: Ambulation helps prevent thrombophlebitis by promoting blood circulation in the lower extremities. Moving the legs and walking encourage the calf muscles to contract, which aids in pushing blood back towards the heart, reducing the risk of blood stasis and clot formation.
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A nurse is reinforcing teaching with a client who is pregnant and reports frequent heartburn.
Which of the following recommendations should the nurse include in the teaching?
- A. Lie in a left side lying position for 30 min after meals
- B. Drink a cup of black coffee before breakfast
- C. Take sips of milk between meals
- D. Eat three large meals per day
Correct Answer: C
Rationale: Taking sips of milk between meals can help neutralize stomach acid and provide temporary relief from heartburn symptoms. However, it's essential to avoid drinking large quantities of milk at once, as this can lead to increased stomach acid production.
A nurse is reinforcing teaching with a client who is pregnant and does not consume dairy products.
Which of the following food options should the nurse recommend as the best source of dietary calcium?
- A. 1 cup kale
- B. 1 baked potato
- C. 1 large banana
- D. 1 cup sweet white corn
Correct Answer: A
Rationale: Kale is an excellent non-dairy source of calcium, providing approximately 90 mg per cup when cooked. It's a suitable option for pregnant women who avoid dairy to meet their calcium needs.
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.
A nurse is reinforcing teaching with a client about various contraceptive methods. Which of the following statements should the nurse include in the teaching?
- A. You will need to receive a medroxyprogesterone acetate injection once per month.
- B. Combined estrogen-progestin contraceptive pills cause longer periods.
- C. Oral contraceptives decrease the risk for endometrial cancer.
- D. You will need to have your diaphragm replaced every 4 years.
Correct Answer: C
Rationale: Oral contraceptives, particularly combined ones, decrease endometrial cancer risk, an important benefit to include in teaching about contraception.
A nurse is reinforcing teaching with a client about laboratory testing during pregnancy. Which of the following statements should the nurse include in the teaching?
- A. A Papanicolaou test will be performed to detect the presence of herpes simplex type 1.
- B. A group B streptococcus screening will be performed to determine the presence of STs.
- C. A multiple marker screening will be performed to identify neural tube defects.
- D. A glucose tolerance test will be performed to predict hyperglycemia in your baby
Correct Answer: C
Rationale: Multiple marker screening, also known as maternal serum screening or quad screen, is a routine prenatal test performed between 15 and 20 weeks of gestation. It helps identify the risk of certain chromosomal abnormalities, including neural tube defects like spina bifida and anencephaly.