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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. Take sips of milk between meals.
- B. Eat three large meals per day.
- C. Drink a cup of black coffee before breakfast.
- D. Lie in a left side-lying position for 30 minutes after meals.
Correct Answer: A
Rationale: Sips of milk neutralize stomach acid, providing heartburn relief, a practical solution for pregnant clients.
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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 has a history of gallbladder disease.
- B. A client who has a positive pregnancy test.
- C. A client who smokes one pack of cigarettes per day.
- D. A client who is nulliparous.
Correct Answer: B
Rationale: An IUD is contraindicated in clients with a positive pregnancy test because it can harm the developing fetus and lead to complications.
A nurse is caring for a client who had a vaginal delivery 4 hours ago and reports perineal pain of 6 on a scale of 0 to 10.
Which of the following actions should the nurse take?
- A. Catheterize the client's bladder.
- B. Apply a corticosteroid cream to the perineal area twice daily.
- C. Offer an ice pack to the client during the first 24 hours.
- D. Increase the client's fluid intake for 48 hours.
Correct Answer: C
Rationale: Offering an ice pack reduces swelling and numbs perineal pain, a standard intervention within the first 24 hours post-delivery.
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. Encourage the client to continue to breastfeed.
- B. Prepare the client for an abdominal sonogram.
- C. Encourage the client to wear a loose-fitting bra.
- D. Limit the client's daily fluid intake.
Correct Answer: A
Rationale: Encouraging the client to continue to breastfeed helps empty the breast, reducing pain and inflammation and promoting healing from mastitis.
Nurses' Notes Two weeks ago (32 weeks gestation): The client presented for a routine visit and denied vaginal bleeding or fluid leakage. Reports mild insomnia and occasional mild uterine cramping. 1+ nonpitting edema noted in bilateral feet and ankles. Weight recorded as 84 kg (185 lb). Today (0930): The client reports mild epigastric pain for the past three days and occasionally 'seeing spots' in her vision. 2+ nonpitting edema noted bilaterally in feet and ankles, and mild facial edema present. The client states her fingers 'swelled up overnight,' preventing her from wearing rings. Weight has increased to 86 kg (190 lb). Vital Signs: Blood pressure: 160/100 mm Hg, Heart rate: 88/min, Respiratory rate: 18/min, Temperature: 36.9°C (98.4°F), Oxygen saturation: 98% on room air. Diagnostic Results: Hemoglobin: 10 g/dL, Hematocrit: 35.9%, Platelet count: 95,000/mm³, AST: 200 U/L, ALT: 25 U/L, Total bilirubin: 1.8 mg/dL, Urine protein: 2+.
Which of the following findings should the nurse report to the primary health care provider?
- A. Platelet count
- B. Hematocrit value
- C. Nonstress test result
- D. Weight gain
- E. Edema
- F. Blood pressure
- G. BUN
Correct Answer: A,D,E,F
Rationale: Low platelets, rapid weight gain, edema, high BP, and proteinuria indicate preeclampsia, requiring immediate reporting.
A nurse is assisting with the care of a client who has been admitted to the labor and delivery unit.
Which of the following diagnostic results should the nurse address first?
- A. Hematocrit 32% (normal range: 32% to 47%).
- B. Hemoglobin 10 g/dL (normal range: 11 to 16 g/dL).
- C. WBC 20,000/mm³ (normal range: 5,000 to 15,000/mm³).
- D. Maternal blood type O negative.
Correct Answer: C
Rationale: An elevated WBC count of 20,000/mm³ suggests infection or inflammation, a priority during labor requiring immediate attention.