Nokea
While assessing the episiotomy site of a primiparous client on the first postpartum day, the nurse observes a fairly large hemorrhoid at the client's rectum. After instructing the client about measures to relieve hemorrhoid discomfort, which of the following client statements indicates the need for additional teaching?
- A. I should try to gently manually replace the hemorrhoid.
- B. Analgesic sprays and witch hazel pads can relieve the pain.
- C. I should lie on my back as much as possible to relieve the pain.
- D. I should drink lots of water and eat foods that have a lot of roughage.
Correct Answer: C
Rationale: Lying on the back increases pressure on hemorrhoids, worsening discomfort; the other statements reflect correct measures.
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While the nurse is assessing the fundus of a multiparous client who delivered 24 hours ago, the client asks, "What can I do to get rid of these stretch marks?" Which of the following responses would be most appropriate?
- A. As long as you don't get pregnant again, the marks will disappear completely.
- B. They usually fade to a silvery-white color over a period of time.
- C. You'll need to use a specially prescribed cream to help them disappear.
- D. If you lose the weight you gained during pregnancy, the marks will fade to a pale pink.
Correct Answer: B
Rationale: Stretch marks typically fade to a silvery-white color over time without specific intervention.
The nurse assesses a primiparous client in labor for 20 hours. The nurse identifies late decelerations on the monitor and initiates standard procedures for the labor client with this wave pattern. Which intravenous should the nurse perform? Select all that apply.
- A. Administering oxygen via mask to the client.
- B. Questioning the client about the effectiveness of pain relief.
- C. Placing the client on her side.
- D. Readjusting the monitor to a more comfortable position.
- E. Applying an internal fetal monitor to help identify the cause of the decelerations.
Correct Answer: A,C
Rationale: Late decelerations indicate uteroplacental insufficiency. Standard interventions include administering oxygen to improve fetal oxygenation and placing the client on her side to enhance uterine perfusion. Questioning pain relief or readjusting the monitor does not address the issue, and internal monitoring may be considered but is not the first step.
The nurse is caring for a 22-year-old G 2, P 2 client who has disseminated intravascular coagulation after delivering a dead fetus. Which findings are the highest priority to report to the health care provider?
- A. Activated partial thromboplastin time(APTT) of 30 seconds.
- B. Hemoglobin of 11.5 g/dL.
- C. Urinary output of 25 mL in the past hour.
- D. Platelets at 149,000/mm3.
Correct Answer: C
Rationale: Decreased urinary output indicates potential renal failure.
A nurse is discussing the contraceptive injection with a client. Which of the following side effects should the nurse mention?
- A. Guaranteed regular periods.
- B. Irregular bleeding and potential weight gain.
- C. Permanent infertility.
- D. Increased risk of breast cancer.
Correct Answer: B
Rationale: The contraceptive injection may cause irregular bleeding and potential weight gain. It does not guarantee regular periods, cause permanent infertility, or significantly increase breast cancer risk.
The nurse assesses a swollen ecchymosed area to the right of an episiotomy on a primiparous client 6 hours after a vaginal delivery. The nurse should next:
- A. Apply an ice pack to the perineal area.
- B. Assess the client's temperature.
- C. Have the client take a warm sitz bath.
- D. Contact the physician for orders for an antibiotic.
Correct Answer: A
Rationale: Applying an ice pack reduces swelling and bruising in the perineal area, which is appropriate for the described symptoms.