A nurse is caring for a client who is experiencing urinary incontinence. Which of the following recommendations should the nurse include in the teaching plan for this client?

Decrease fiber intake.

Avoid Kegel exercises.

Restrict fluid intake to 1 liter per day.

Reduce intake of caffeinated and carbonated beverages.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Decreasing fiber intake is not a recommended action for urinary incontinence. Fiber intake is related to bowel health and does not directly affect urinary incontinence.

Choice B rationale:

Avoiding Kegel exercises is not recommended for urinary incontinence. Kegel exercises are beneficial for strengthening the pelvic floor muscles, which can help improve urinary continence.

Choice C rationale:

Restricting fluid intake to 1 liter per day is not advisable for urinary incontinence. Adequate hydration is essential for overall health, and limiting fluid intake can lead to dehydration and other health issues.

Choice D rationale:

Reducing intake of caffeinated and carbonated beverages is a helpful recommendation for a client experiencing urinary incontinence. Caffeine and carbonation can irritate the bladder and worsen incontinence symptoms.

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Correct Answer is B

Explanation

Choice A rationale:

Assisting the client to a sitz bath is not the priority action in this situation. The client has soaked two perineal pads in the past 30 minutes, indicating excessive bleeding, which requires immediate attention.

Choice B rationale:

Assessing the client's uterine tone is essential to determine if the uterus is contracting appropriately. Uterine atony, where the uterus fails to contract after childbirth, is a common cause of postpartum hemorrhage. Assessing the tone helps identify this issue and allows for timely interventions.

Choice C rationale:

Encouraging the client to breastfeed may have benefits such as promoting uterine contractions through oxytocin release. However, the priority in this scenario is addressing the potential postpartum hemorrhage.

Choice D rationale:

Applying an ice pack to the client's perineum may provide comfort, but it does not address the concerning symptom of excessive bleeding and potential postpartum hemorrhage.

A. The client's blood does not contain the Rh factor, so she produces anti-Rh antibodies that cross the placental barrier and cause hemolysis of red blood cells in newborns. B. The client's blood contains the Rh factor, and the newborn's does not, and antibodies that destroy red blood cells are formed in the fetus. C. The client has a history of receiving a transfusion with Rh-negative blood. D. The client's anti-A and anti-B antibodies cross the placenta and cause the destruction of the fetal red blood cells.

Correct Answer is A

Explanation

Choice A rationale:

Rh incompatibility occurs when an Rh-negative client is exposed to Rh-positive fetal blood, typically during a prior pregnancy or delivery. The client’s immune system produces anti-Rh antibodies that cross the placenta in subsequent pregnancies, attacking the Rh-positive red blood cells of the fetus. This hemolysis releases bilirubin, leading to hyperbilirubinemia in the newborn.

Choice B rationale:

Rh incompatibility only occurs when the client is Rh-negative and the fetus is Rh-positive. An Rh-positive client will not form antibodies against an Rh-negative fetus, as their immune system recognizes the Rh factor as normal.

Choice C rationale:

This choice is not related to the mechanism of Rh incompatibility. Receiving a transfusion with Rh-negative blood would not cause the mother's immune system to produce anti-Rh antibodies or lead to Rh incompatibility with her newborn.

Choice D rationale:

This choice describes the ABO blood group system, not the Rh factor. ABO incompatibility can occur when a mother with blood type O (producing anti-A and anti-B antibodies) has a newborn with blood type A, B, or AB, leading to hemolysis of the fetal red blood cells. However, the question specifically mentions Rh incompatibility, which involves the Rh factor, not the ABO system.

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A nurse is caring for a client who is experiencing urinary incontinence. Which of the following recommendations should the nurse include in the teaching plan for this client?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who had a vaginal birth 2 hr ago and has soaked two perineal pads in the past 30 min. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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