A nurse is reinforcing teaching with a client who has gestational hypertension about collecting a 24-hr urine specimen for protein. Which of the following statements should the nurse include in the teaching?
"Cleanse your perineum with povidone-iodine prior to collecting each urine specimen."
"You should start the 24-hour collection with your first urination."
"You should record the time on the collection container of any missed urine specimens."
"Do not add a urine specimen to the collection container if it contains stool
The Correct Answer is C
A) Incorrect- Cleansing the perineum with povidone-iodine is not relevant to the collection process.
B) Incorrect- The 24-hour collection should start with the first-morning urination, not with any random urination.
C) Correct - Recording the time on the collection container for any missed urine specimens is important for accurate measurement.
D) Incorrect- Stool should not be added to the urine collection container, but this is not the most important point to emphasize in this teaching.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect- Calcium is important for bone health but is not directly related to increasing maternal blood volume.
B) Incorrect- Vitamin E is an antioxidant that helps protect cells from damage but is not directly related to increasing maternal blood volume.
C) Correct - Iron is essential for hemoglobin production, which is necessary to support the increase in maternal blood volume during pregnancy.
D) Incorrect- Vitamin D is important for bone health and calcium absorption but is not directly related to increasing maternal blood volume.
Correct Answer is D
Explanation
Rationale:
A) Incorrect - Applying oxygen is not the priority action in the case of excessive vaginal bleeding and a boggy uterus. Oxygen therapy would be appropriate if there were signs of respiratory distress or decreased oxygen saturation, but it does not directly address the primary concern of uterine atony and bleeding.
B) Incorrect - Administering methylergonovine might be appropriate, but the priority is to address the uterine atony with fundal massage first. Fundal massage helps stimulate uterine contractions and control bleeding, which is crucial in this scenario.
C) Incorrect - Encouraging the client to empty her bladder is important, but it is not the first action to take in the case of excessive bleeding and uterine atony. Immediate intervention to control the bleeding takes precedence.
D) Correct - Initiating fundal massage is the priority action in this situation. A boggy uterus with excessive vaginal bleeding indicates uterine atony, which is a potentially life-threatening condition requiring immediate intervention to prevent further bleeding.
Fundal massage helps the uterus contract and control bleeding. Addressing uterine atony is critical to prevent further hemorrhage and stabilize the client's condition.
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