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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.
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A nurse in an obstetric clinic is caring for four clients.
The nurse should identify that an intrauterine device is contraindicated for which of the following clients?
- A. A client who smokes one pack of cigarettes per day
- B. A client who has a history of gallbladder disease
- C. A client who has a positive pregnancy test
- D. A client who is nulliparous
Correct Answer: C
Rationale: An IUD should not be inserted in a client who has a positive pregnancy test. Inserting an IUD during pregnancy can lead to complications such as infection, miscarriage, and preterm birth. It is crucial to confirm the absence of pregnancy before IUD insertion.
A nurse is assisting with the care of a client who is in labor and has received nalbuphine hydrochloride.
Which of the following manifestations should the nurse identify as an adverse effect of this medication?
- A. Diuresis
- B. Fever
- C. Diarrhea
- D. Sedation
Correct Answer: D
Rationale: Nalbuphine hydrochloride is an opioid analgesic used for pain relief during labor. Sedation is a common adverse effect of opioid medications, including nalbuphine, due to central nervous system depression, leading to drowsiness and decreased consciousness.
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.
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 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.