A nurse is speaking on the phone to a client on the phone who is pregnant and taking iron supplements for iron-deficiency anemia. The client reports that her stools are black but she has no abdominal pain or cramping. Which of the following responses by the nurse is appropriate?

"Go to the emergency room and your provider will meet you the

"Come to the office and we will check things out."

"What else have you been eating?"

"This is expected because of the way iron is broken down during digestion."

Answer and Explanation

The Correct Answer is D

Choice A rationale:
Going to the emergency room for black stools without abdominal pain or cramping is not warranted in this situation.
Choice B rationale:
Having the client come to the office to check things out may not be necessary since black stools can be an expected side effect of iron supplements and do not necessarily indicate a problem.
Choice C rationale:
Asking about the client's diet is a valid question, but the black stools are likely due to iron supplements' effects and not related to dietary choices.
Choice D rationale:
Black stools are a known side effect of iron supplements. When iron is broken down during digestion, it can cause the stools to appear black or dark. As the client has no other concerning symptoms like abdominal pain or cramping, this response by the nurse reassures the client that the finding is expected and not a cause for alarm.

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Correct Answer is A

Explanation

Choice A rationale: Weight loss in the first few days after birth is normal for newborns, and a weight loss of up to 7-10% of the birth weight is considered within the expected range. A 6% weight loss is within normal limits, and it is reassuring to inform the mother that this is typical.
Choice B rationale: Suggesting switching to formula is not necessary based on the weight loss described. Breastfeeding provides adequate nutrition for most newborns, and early weight loss is typical and not a cause for alarm.
Choice C rationale: While it is true that new mothers may worry about breastfeeding and milk supply, this response does not address the specific weight loss concern and might not fully reassure the mother.
Choice D rationale: A 6% weight loss is within the expected range for a newborn and does not warrant hospitalization. It is a normal finding, and most newborns will start to regain their birth weight within a few days of life.

A. Encourage the client to nurse more frequently so her milk will come in. B. Report the client's temperature elevation. C. Increase IV fluids. D. Ask the client to empty her bladder.

Correct Answer is D

Explanation

A. Breast engorgement typically occurs around days 3 to 5 postpartum, so encouraging frequent nursing at 14 hours postpartum will not impact milk production at this stage.
B. A temperature of 37.7°C (100°F) is a normal postpartum finding due to dehydration and hormonal changes. It does not require reporting unless it exceeds 38°C (100.4°F).
C. Increasing IV fluids is not necessary unless there is evidence of dehydration or another medical indication.
D. A slightly deviated fundus suggests bladder distension, which can interfere with uterine involution. Asking the client to empty her bladder helps the uterus contract properly and prevents complications such as postpartum hemorrhage.

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A nurse is speaking on the phone to a client on the phone who is pregnant and taking iron supplements for iron-deficiency anemia. The client reports that her stools are black but she has no abdominal pain or cramping. Which of the following responses by the nurse is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes: breasts soft, fundus firm, slightly deviated to the right moderate lochia rubra; temperature 37.7° C (100° F), pulse rate 88./min, respiratory rate 18/min. Which of the following actions should the nurse perform?

Correct Answer is D

Explanation

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