A nurse is providing teaching to a client who has fibrocystic breast changes and is experiencing breast discomfort during menstruation. Which of the following instructions should the nurse include?

"Increase potassium intake.”

"Increase fluid intake to 3 liters per day.”

"Decrease sodium intake before menstruation.”

"Decrease daily fiber intake.”

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Increasing potassium intake is not specifically associated with relieving breast discomfort during menstruation. There is no established link between potassium intake and fibrocystic breast changes.

Choice B rationale:

Increasing fluid intake is generally beneficial for overall health, but it is not a specific recommendation for managing breast discomfort during menstruation. It may not have a direct impact on fibrocystic breast changes.

Choice C rationale:

Decreasing sodium intake before menstruation is a relevant instruction for managing breast discomfort associated with fibrocystic breast changes. High sodium intake can lead to water retention and breast swelling, exacerbating discomfort.

Choice D rationale:

Daily fiber intake is important for bowel health but is not directly related to managing breast discomfort during menstruation or fibrocystic breast changes.

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Correct Answer is ["B","C"]

Explanation

Choice A rationale:

Edema is not an expected finding of uncomplicated gestational hypertension. While some degree of edema can be common during pregnancy, it is not specifically related to gestational hypertension.

Choice B rationale:

A blood pressure reading of 155/92 is an expected finding in a client with uncomplicated gestational hypertension. Gestational hypertension is defined as systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg after 20 weeks of pregnancy, without the presence of proteinuria or other organ dysfunction.

Choice C rationale:

Proteinuria is an expected finding in gestational hypertension. It is an important diagnostic criterion for preeclampsia, which is a severe form of gestational hypertension.

Choice D rationale:

Hepatic dysfunction is not an expected finding in uncomplicated gestational hypertension. Hepatic dysfunction would indicate more severe complications such as HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelet count), which is a medical emergency.

Choice E rationale:

Blood pressure usually returns to normal after pregnancy in women with uncomplicated gestational hypertension. However, it is essential to monitor the client closely postpartum to ensure blood pressure normalization.

A. Assist the client to void then reassess the fundus. B. Document the findings as within normal limits. C. Gently massage the client's fundus. D. Encourage the client to ambulate.

Correct Answer is A

Explanation

Choice A rationale:

Assisting the client to void is a priority intervention in this situation. A full bladder can displace the uterus and prevent it from contracting effectively, leading to a boggy and high- positioned fundus. After the client empties her bladder, the nurse should reassess the fundus to ensure it has descended to its appropriate location, which is usually at or just below the level of the umbilicus.

Choice B rationale:

Documenting the findings as within normal limits is incorrect because a firm, displaced fundus that is 3 cm above the umbilicus is not considered normal. This finding indicates that the uterus is not contracting adequately, and the nurse should take appropriate actions to address the issue.

Choice C rationale:

Gently massaging the client's fundus is not the correct intervention in this case. Massaging a firm fundus could cause uterine irritation and should be avoided. Instead, the nurse should encourage the client to empty her bladder, which often helps the uterus contract and descend to its proper position.

Choice D rationale:

Encouraging the client to ambulate may be helpful in some cases to promote uterine contractions and involution. However, in this situation, the priority is to address the full bladder, as it is a common cause of a displaced and high fundus shortly after delivery.

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A nurse is providing teaching to a client who has fibrocystic breast changes and is experiencing breast discomfort during menstruation. Which of the following instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with uncomplicated gestational hypertension. Which are expected findings of the disorder? Select all that apply.

Correct Answer is ["B","C"]

Explanation

A postpartum client's fundus is firm, 3 cm above the umbilicus, and displaced to the right. Which of the following interventions should the nurse take?

Correct Answer is A

Explanation

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