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Which of the following would the nurse include in the teaching plan for a 16-year-old primigravid client in early labor concerning active relaxation techniques to help her cope with pain?
- A. Relaxing uninvolved body muscles during uterine contractions.
- B. Practicing being in a deep, meditative, sleeplike state.
- C. Focusing on an object in the room during the contractions.
- D. Breathing rapidly and deeply between contractions.
Correct Answer: A
Rationale: Active relaxation involves consciously relaxing uninvolved muscles (e.g., face, arms) during contractions to conserve energy and reduce tension, aiding pain management. Meditation is less practical during active labor, focusing on an object is a distraction technique, and rapid breathing between contractions may cause hyperventilation.
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Which of the following instructions about activities during menstruation would the nurse include when counseling an adolescent who has just begun to menstruate?
- A. Take a mild analgesic if needed for menstrual pain.
- B. Avoid cold foods if menstrual pain persists.
- C. Stop exercise while menstruating.
- D. Avoid sexual intercourse while menstruating.
Correct Answer: A
Rationale: Mild analgesics like ibuprofen can effectively manage menstrual pain. There is no evidence supporting avoiding cold foods, and moderate exercise can alleviate cramps. Sexual intercourse during menstruation is a personal choice and not medically contraindicated.
While assessing the fundus of a multiparous client 36 hours after delivery of a term neonate, the nurse notes a separation of the abdominal muscles. The nurse should tell the client:
- A. She will have a surgical repair at 6 weeks postpartum.
- B. To remain on bed rest until resolution occurs.
- C. The separation will resolve on its own with the right posture and diet.
- D. To perform exercises involving head and shoulder raising in a lying position.
Correct Answer: D
Rationale: Diastasis recti often resolves with specific exercises like head and shoulder raises, which strengthen abdominal muscles.
A multigravid client is admitted at 16 weeks' gestation with a diagnosis of hyperemesis gravidarum. The nurse should explain to the client that hyperemesis gravidarum is thought to be related to high levels of which of the following hormones?
- A. Progesterone.
- B. Estrogen.
- C. Somatotropin.
- D. Aldosterone.
Correct Answer: B
Rationale: High estrogen levels are associated with hyperemesis gravidarum.
A newborn with a cleft palate at 1 hour of life has a nursing diagnosis of Risk for Infection related to potential aspiration during feedings. Which of the following nursing actions would support the best feeding practice for this infant?
- A. Use an appropriate nipple and bottle set.
- B. Encourage the mother to breast-feed.
- C. Assess daily weights and wet diapers to monitor intake.
- D. Allow unlimited length of time for each feeding.
Correct Answer: A
Rationale: Using an appropriate nipple and bottle set designed for cleft palate infants minimizes aspiration risk during feedings.
A breast-feeding primiparous client who delivered 8 hours ago asks the nurse, "How will I know that my baby is getting enough to eat?" Which of the following guidelines should the nurse include in the teaching plan as evidence of adequate intake?
- A. Six to eight wet diapers by the fifth day.
- B. Three to four transitional stools on the fourth day.
- C. Ability to fall asleep easily after feeding on the first day.
- D. Regain of lost birth weight by the third day.
Correct Answer: A
Rationale: Six to eight wet diapers by the fifth day indicate adequate milk intake.