A nurse is assessing a client two weeks postpartum. Which of the following statements by the client indicates a need for further evaluation?

“I am so relieved the baby looks like my mother."

"My appetite has really increased."

"My labor was so long. I'm glad it's over."

"I really wish I had a girl instead”

Answer and Explanation

The Correct Answer is D

A. “I am so relieved the baby looks like my mother.”: Feeling relief or comfort when noticing family resemblance in the newborn is a common emotional response. It generally reflects normal adjustment and bonding with the baby and does not indicate emotional distress requiring further evaluation.

B. “My appetite has really increased.”: Increased appetite postpartum can be a normal physiological response, especially with breastfeeding, as the body requires additional calories. It does not usually indicate a mental health concern or a need for further evaluation.

C. “My labor was so long. I'm glad it's over.”: Expressing relief or fatigue after a prolonged labor is a typical postpartum response. It shows processing of the birth experience and adjustment to recovery and newborn care, which does not warrant immediate concern.

D. “I really wish I had a girl instead.”: Expressing regret or disappointment regarding the baby’s sex may indicate difficulty bonding, gender preference stress, or emerging postpartum mood disturbances. This statement warrants further assessment for postpartum depression, anxiety, or adjustment issues to ensure maternal-infant wellbeing.

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Correct Answer is D

Explanation

A. Attach a blood pressure cuff to the client's upper arm: A blood pressure cuff is not required for obtaining a 12-lead ECG. Its use does not contribute to the quality of the ECG tracing and is unnecessary during this procedure.

B. Tell the client to expect a mild stinging sensation during the test: A 12-lead ECG is noninvasive and painless. Electrodes are placed on the skin with adhesive gel or pads, and clients typically feel no stinging. Providing accurate expectations helps reduce anxiety.

C. Assist the client to the orthopneic position: The orthopneic position is used to ease breathing in clients with respiratory distress. For a 12-lead ECG, the client should lie supine to ensure proper electrode placement and accurate readings.

D. Instruct the client to remain as still as possible during the recording: Movement can create artifacts on the ECG tracing, making interpretation difficult. Remaining still ensures accurate detection of cardiac electrical activity and reliable diagnostic results.

A. A B. B C. C D. D E. None F. None

Correct Answer is A

Explanation

A. Right upper quadrant of the abdomen: An open cholecystectomy involves surgical removal of the gallbladder, which is located in the right upper quadrant beneath the liver. The incision is typically made just below the right rib cage, making area A the correct site for the dressing change.

B. Midline of the upper abdomen: This area corresponds to the epigastric region and would not align with the typical location for a gallbladder incision. Incisions here are more common for other abdominal surgeries, such as exploratory laparotomy.

C. Lower midline abdomen: This area is associated with procedures involving the lower gastrointestinal tract, such as appendectomy or hysterectomy, and is not consistent with a cholecystectomy incision.

D. Right lower quadrant: This region is typically related to surgeries involving the appendix, cecum, or right ovary, not the gallbladder. Selecting this area would not correspond to the correct postoperative site for a cholecystectomy.

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A nurse is assessing a client two weeks postpartum. Which of the following statements by the client indicates a need for further evaluation?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Correct Answer is A

Explanation

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