A nurse is reinforcing teaching with a client at her first prenatal visit about expected changes during gestation. (Arrange the steps in order, placing them in the selected order of occurrence from earliest to latest in gestation. Use all the steps.)
Breast tenderness
Nausea and vomiting
Quickening
Goodell's sign
Striae gravidarum
Lightening
Correct Answer : A,B,C,D,E,F
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should check the client's fundus first, as this is the most likely source of bleeding and clots in the postpartum period. The fundus is the upper part of the uterus that contracts and involutes after delivery to prevent hemorrhage. The nurse should palpate the fundus for firmness, height, and position, and massage it gently if it is boggy or displaced. A soft, high, or deviated fundus may indicate uterine atony or retained placental fragments, which can cause excessive bleeding and clots.
Correct Answer is C
Explanation
c. "This is expected because of the way iron is broken down during digestion."
The client's stools are black because of the iron supplements, which can cause a harmless change in the color and consistency of the stools. This is due to the oxidation of iron in the gastrointestinal tract, which produces a black pigment called ferrous sulfide. This is not a sign of bleeding or infection and does not require further evaluation or treatment. The nurse should reassure the client that this is a normal side effect of iron supplements and advise her to continue taking them as prescribed.
The other responses are not appropriate and may cause unnecessary anxiety or inconvenience for the client.
The nurse should not ask the client what else she has been eating, as this implies that her diet may be causing her stools to be black. This may confuse or offend the client, who may think that the nurse is questioning her nutritional choices or blaming her for her condition.
The nurse should not tell the client to go to the emergency room, as this suggests that her stools are black because of a serious problem that needs immediate atention. This may frighten or alarm the client, who may think that she or her baby are in danger.
d. The nurse should not tell the client to come to the office, as this indicates that her stools are black because of an abnormal finding that needs further investigation. This may worry or inconvenience the client, who may think that she has a complication or infection that requires testing or treatment.
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