A client in preterm labor is to receive a tocolytic medication, and bedrest is prescribed. Which position should the nurse suggest that the client maintain while on bedrest?
1
Lateral
2
Supine
3
Fowler
4
Semi-Fowler
1
Lateral
The lateral position relieves pressure on the vena cava, thereby promoting venous return and increasing placental perfusion. The supine position promotes hypotension because the pressure of the gravid uterus on the vena cava interferes with the return of blood from the lower extremities. The Fowler position promotes hypotension because the pressure of the gravid uterus on the vena cava interferes with the return of blood from the lower extremities. The semi-Fowler position promotes hypotension because the pressure of the gravid uterus on the vena cava interferes with the return of blood from the lower extremities.
A
nurse is caring for a client with vaginal bleeding caused by placenta previa. What is the best nursing intervention to delay the birth of the fetus?
1
Maintaining bed rest
2
Planning for an ultrasound test
3
Preparing for a nonstress test
4
Administering oxygen by way of a mask
1
Maintaining bed rest
Gravitational pull on an already stressed placenta may cause further bleeding; bedrest limits stress. Planning for an ultrasound test or a nonstress test provides for fetal assessment; it does not delay the birth. Unless the fetal heart rate is decelerating, oxygen supplementation is not necessary.
A woman who was discharged recently from the hospital after undergoing a hysterectomy calls the clinic and states that she has tenderness, redness, and swelling in her right calf. What should the nurse instruct the client to do?
1
Stay in bed for at least 3
days.
2
Keep the legs elevated while sitting.
3
Apply a warm compress to the affected calf twice a day.
4
Call an ambulance to go to the emergency department.
4
Call an ambulance to go to the emergency department.
The client's description of her problem is indicative of thrombophlebitis; this is a medical emergency because it may precipitate a pulmonary embolism. The client must be assessed by a health care provider. Intravenous anticoagulants will probably be necessary. Although bedrest may be prescribed eventually, a delay in pharmacological treatment may jeopardize the client's status. Elevation of the legs may be prescribed eventually, after the thrombophlebitis is resolved. Although warm compresses are frequently prescribed, a delay in pharmacological treatment may jeopardize the client's status.
A client with a large fetus is to have a pudendal block during the
second stage of labor. What does the nurse plan to instruct the client about the effectiveness of the block? (Select all that apply.)
1
Contractions will decrease.
2
Perineal pain will not be felt.
3
Bladder sensation may be lost.
4
An episiotomy may not be needed.
5
The bearing-down reflex will be diminished.
2
Perineal pain will not be felt.
5
The bearing-down reflex will be diminished.
The block provides anesthesia to the perineum, after which pain is not felt. Although the bearing-down reflex is diminished, muscle control is not affected and the client is able to bear down with contractions. The block affects only the perineum, not the bladder. The block does not influence the decision of whether to have an episiotomy. The block results in anesthesia of the perineum, not the cervix or the body of the uterus.
What should a nurse include in the
discharge instructions for a woman who has undergone breast-conserving surgery (lumpectomy) for breast cancer?
1
Assuring her that a supportive brassiere is unnecessary
2
Emphasizing the importance of breast self-examination
3
Instructing her to return the next day for removal of the drain
4
Explaining why it is unnecessary to exercise the arm on the unaffected side
2
Emphasizing the importance of breast self-examination
A client who has cancer of one breast is at risk for the development of cancer in the remaining breast; therefore breast self-examination is important. Wearing a supportive brassiere limits incisional discomfort. There may or may not be a wound drainage system in place, and the timing of its removal is individualized. With the removal of breast tissue specific exercises are needed to prevent muscle atrophy and contractures; the right and left arms should be exercised at the same time.
A nurse is caring for a client who is receiving internal radiation for cancer of the cervix. For which adverse reactions to the radiotherapy should the client be monitored? (Select all that apply.)
1
Nausea
2
Hemorrhage
3
Restlessness
4
Vaginal discharge
5
Increased temperature
2
Hemorrhage
5
Increased temperature
Excessive sloughing of tissue may cause hemorrhage and is considered an adverse reaction. Infection, marked by an increase in temperature, may also develop from excessive sloughing of tissue. Nausea is an expected side effect of internal radiotherapy. Restlessness is not a sign of an adverse reaction; it is associated with a need to maintain a set position to prevent the applicator from being dislodged. Vaginal discharge is an expected side effect of internal radiotherapy.
An adolescent who gave birth
one day ago confides to the nurse that she hopes that her baby will be good and sleep through the night. What should the nurse include in the plan of care to facilitate a realistic expectation of a nighttime newborn schedule?
1
Talk softly and cuddle the baby when crying occurs
2
Keep the baby awake for longer periods during the day
3
Ensure sleep by adding cereal to the baby's bedtime bottle
4
Put a soft, brightly colored toy next to the baby at bedtime
1
Talk softly and cuddle the baby when crying occurs
The mother needs to learn the realities of infant behaviors and how to cope with them; holding and talking to her infant are consoling measures. It is unhealthy to disrupt a neonate's sleep pattern . The infant is too young to be given cereal. According to the American Academy of Pediatrics, a soft toy is not appropriate in a crib unless it adheres to the crib because of the risk to the newborn.
The nurse reads the history of a neonate admitted to the nursery and discovers that the infant's mother was listed as gravida 1 para 1 before the baby was born. How should the nurse use these data to gather more information?
1
To determine whether there were previous fetal losses
2
To determine whether there are twins at home
3
To consider that someone recorded the gravida and para incorrectly
4
To consider that the current birth means
that there were two pregnancies
3
To consider that someone recorded the gravida and para incorrectly
Gravida refers to pregnancies, including this one, and para refers to pregnancies terminated (by whatever means) after the age of viability. If this is the client's only pregnancy (gravida 1) she could not have had a previous pregnancy that ended after the age of fetal viability. Para will not exceed gravida. One pregnancy is gravida 1. A twin pregnancy is still one pregnancy terminated after the age of viability. Because the documentation of the client indicates that she is gravida 1, it cannot be assumed that it is the woman's second pregnancy.
The husband of a woman who had her fourth child 3 weeks ago states she has been irritable and crying frequently since bringing her newborn home. He asks the nurse whether this is normal. The nurse tries to help him understand the situation by stating
that:
1
Having four children is tiring and assistance may be needed.
2
His wife probably has the postpartum blues, but it will soon pass.
3
This behavior is common after birth, and he should not be too concerned.
4
Women often express themselves by crying, and he should allow her to continue.
1
Having four children is tiring and assistance may be needed.
This statement acknowledges the situation and suggests a possible solution to the problem. Postpartum blues occurs earlier; this may be postpartum depression , and it should not be taken lightly. Stating that this behavior is common after birth and the husband should not be too concerned not only constitutes false reassurance but also fails to address the problem that is evident in the situation. Stating that women often express themselves by crying and that he should allow her to continue is stereotyping and nontherapeutic.
A
nurse is teaching a postpartum client the characteristics of lochia and any deviations that should be reported immediately. What client statement indicates that the teaching was effective?
1
"If I pass any clots, I'll notify the clinic."
2
"I'll call the clinic if my lochia changes from red to pink."
3
"I'll notify the clinic if my lochia starts to smell bad."
4
"If my vaginal discharge continues for three weeks, I'll call the clinic."
3
"I'll
notify the clinic if my lochia starts to smell bad."
Lochia has a characteristic menstrual musky or fleshy smell. A foul-smelling discharge, along with fever and uterine tenderness, suggests an infection. Passing clots is a common occurrence. Lochia changing from red to pink is expected as lochia rubra progresses to lochia serosa. Although many women have a minimal discharge after 2 weeks, it is not uncommon for lochia alba to last 6 weeks.
The
nurse discusses the recommended weight gain during pregnancy with a newly pregnant client who is 5 feet 3 inches tall and weighs 125 lb. The nurse explains that with the recommended weight gain, at term the client should weigh about:
1
150 lb
2
140 lb
3
135 lb
4
130 lb
1
150 lb
A weight of 150 lb would put the client within the recommended weight gain of at least 25 lb for a woman who was of average weight for her height before pregnancy. A weight of 140 lb is less than the recommended weight gain for a woman of average weight for height before pregnancy, as are 135 lb and 130 lb.