A nurse is providing teaching about self-care to a primigravid client who is at 9 weeks of gestation. Which of the following statements should the nurse include?
"You will feel your baby moving within the next month."
"Hormone shifts often cause vulvar itching."
"You should consume at least 3 liters of fluid each day."
“Headaches are expected throughout pregnancy"
The Correct Answer is C
A. "You will feel your baby moving within the next month." Fetal movement, or quickening, is typically felt between 16 and 20 weeks of gestation. At 9 weeks, it is too early for the client to detect fetal movement.
B. "Hormone shifts often cause vulvar itching." Vulvar itching is not a common or expected symptom of early pregnancy and may indicate an infection, such as a yeast infection, rather than a normal hormonal change.
C. "You should consume at least 3 liters of fluid each day." Adequate hydration is essential during pregnancy to support increased blood volume, amniotic fluid, and metabolic processes. A daily intake of about 3 liters of fluid helps prevent dehydration and constipation.
D. “Headaches are expected throughout pregnancy." While headaches can occur, especially in the first trimester due to hormonal changes, persistent or severe headaches may indicate complications like preeclampsia and should not be considered a normal, ongoing expectation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Place a warm, wet washcloth over your child's forehead and the bridge of their nose." Warm compresses may actually dilate blood vessels, which can worsen the bleeding. Cold compresses are preferred to help constrict vessels.
B. "Use your thumb and forefinger to apply pressure to the sides of your child's nose." This is the correct first-aid measure for epistaxis. The parent should pinch the soft part of the nose continuously for 10–15 minutes while the child leans forward.
C. "Have your child lie down and turn their head to the side for 10 minutes." Lying down can increase blood flow to the nose and may cause blood to be swallowed, which can lead to nausea or vomiting.
D. “Tell your child to blow their nose gently, and then sit down and tilt their head backward." Tilting the head back can cause blood to drain into the throat, increasing the risk of aspiration and stomach upset. Leaning forward is the proper position.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E"}
Explanation
- Tocolytic medication: Tocolytics are used to suppress preterm labor, which is not applicable for this postpartum client. There is no indication of uterine contractions needing suppression.
- Intravenous antibiotic: The client exhibits signs of postpartum endometritis—including fever, uterine tenderness, foul-smelling lochia, and a very high WBC count (33,000/mm³). These findings strongly support the need for IV antibiotics to treat the infection.
- Intrauterine tamponade balloon: This device is used for managing postpartum hemorrhage, which is not present in this case. The client’s lochia is moderate, not excessive, and her uterus is responding to massage.
- Kleihauer-Betke test: This test is used to detect fetal-to-maternal hemorrhage, particularly in Rh-negative mothers after trauma or potential placental separation. It is not relevant in the context of postpartum infection.
- Increase in daily fluid intake: The client is febrile and shows signs of systemic infection. Increased fluids support hydration, promote recovery, and help manage the effects of fever and infection, making this an appropriate supportive measure.
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