Nokea
While caring for a primipara diagnosed with deep vein thrombosis at 48 hours postpartum who is receiving treatment with bed rest and intravenous heparin therapy, the nurse should contact the client's physician immediately if the client exhibited which of the following?
- A. Pain in her calf.
- B. Dyspnea.
- C. Hypertension.
- D. Bradycardia.
Correct Answer: B
Rationale: Dyspnea may indicate a pulmonary embolism, a life-threatening complication requiring immediate attention.
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A primigravid client who has had a prolonged labor but now is completely dilated has received epidural anesthesia. Which of the following should the nurse include in the teaching plan about pushing?
- A. The client needs to push for at least 1 to 3 minutes.
- B. Pushing is most effective when the client holds her breath.
- C. The client should be urged to push with an open glottis.
- D. Pushing is limited to times when she feels the urge.
Correct Answer: C
Rationale: Pushing with an open glottis (exhaling during effort) is effective and reduces the risk of Valsalva maneuver complications. Prolonged pushing (1–3 minutes) is unrealistic, holding breath is discouraged, and with epidurals, the urge to push may be diminished.
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.
A primiparous client, 4 hours postpartum, reports feeling overwhelmed and anxious about caring for her newborn. Which nursing intervention is most appropriate?
- A. Encourage the client to rest and limit visitors.
- B. Teach the client basic newborn care skills immediately.
- C. Administer an anxiolytic medication as prescribed.
- D. Refer the client to a social worker for counseling.
Correct Answer: B
Rationale: Teaching basic newborn care skills empowers the client, reduces anxiety, and promotes confidence in the early postpartum period.
When assessing the frequency of contractions of a multiparous client in active labor admitted to the birthing area, the nurse should assess the interval between which of the following?
- A. Acme of one contraction to the beginning of the next contraction.
- B. Beginning of one contraction to the end of the next contraction.
- C. End of one contraction to the end of the next contraction.
- D. Beginning of one contraction to the beginning of the next contraction.
Correct Answer: D
Rationale: Contraction frequency is measured from the beginning of one contraction to the beginning of the next, capturing the full cycle and rest period, which is critical for assessing labor progress.
A 36-year-old multigravid client is admitted to the hospital with possible ruptured ectopic pregnancy. When obtaining the client's history, which of the following would be most important to identify as a predisposing factor?
- A. Urinary tract infection.
- B. Marijuana use during pregnancy.
- C. Episodes of pelvic inflammatory disease.
- D. Use of estrogen-progestin contraceptives.
Correct Answer: C
Rationale: Pelvic inflammatory disease increases the risk of ectopic pregnancy.