A nurse is speaking on the phone to a client who is pregnant and taking iron supplements for iron-deficiency anaemia. 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 there.".
"What else have you been eating?.".
"This is expected because of the way iron is broken down during digestion.".
"Come to the office, and we will check things out.".
The Correct Answer is C
Choice C rationale:
This response is correct because black stools are a common side effect of taking iron supplements. Iron can cause the stool to appear black or
tarry due to the way it is broken down during digestion. It does not necessarily indicate a serious issue, especially if the client is not experiencing any abdominal pain or cramping. Educating the client about this expected side effect helps alleviate any concerns they might have about the change in stool colour.
Choice A rationale:
"Go to the emergency room and your provider will meet you there.”. This response is not appropriate in this situation. The client's report of black stools without abdominal pain or cramping is likely due to the iron supplements and does not warrant a visit to the emergency room. This response may cause unnecessary panic and anxiety for the client.
Choice B rationale:
"What else have you been eating?.”. This response is also not the best choice. While it's essential for healthcare providers to gather comprehensive information about a client's diet and lifestyle, in this case, the client's black stools can be directly attributed to the iron supplements. Focusing on other dietary factors might distract from addressing the client's concern about the side effect of iron supplementation.
Choice D rationale:
"Come to the office, and we will check things out.”. This response is not the most appropriate one either. A visit to the office might not be necessary solely based on the client's report of black stools without accompanying pain or cramping. This situation can be managed through education, and the client can be reassured that it is a typical side effect of iron supplements. An unnecessary visit to the office could inconvenience the client and waste both their time and the healthcare provider's time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Vaginal hematoma is not the most significant risk in the 4th stage of labor. While vaginal hematomas can occur due to trauma during delivery, they are less common and usually manageable compared to other complications.
Choice B rationale:
Hypoglycemia is not a typical complication in the 4th stage of labor. This stage refers to the immediate postpartum period, during which the mother's blood sugar levels may decrease slightly, but it is not the greatest concern at this stage.
Choice C rationale:
Chorioamnionitis is an infection of the fetal membranes and amniotic fluid. While it can be a concern during labor, the question specifically refers to the 4th stage, which occurs after the delivery of the placenta. Chorioamnionitis is more relevant to earlier stages of labor.
Choice D rationale:
Uterine hemorrhage is the greatest risk during the 4th stage of labor. This stage, also known as the "placental stage,”. is when the uterus contracts to expel the placenta. If the uterus fails to contract adequately, it can lead to significant bleeding, known as postpartum hemorrhage. This is a critical concern that requires immediate attention to prevent complications.
Choice E rationale:
Dehiscence, which refers to the reopening of a surgical wound, is not a common complication during the 4th stage of labor. The 4th stage primarily focuses on uterine contraction and placental delivery, making dehiscence less relevant in this context.
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale:
The nurse should report the blood pressure findings to the provider because there is a significant increase in both systolic and diastolic blood pressure. At 0900, the blood pressure was 156/90 mm Hg, and at 1000, it increased to 160/96 mm Hg. This significant elevation in blood pressure can be a cause for concern as it may indicate the development of gestational hypertension or preeclampsia, which can be dangerous for both the client and the fetus.
Choice B rationale:
Cerebral manifestations are not mentioned in the nurse's notes or vital signs and are not relevant to the given scenario. Therefore, this choice is not applicable in this case.
Choice C rationale:
The nurse should report the fetal heart rate findings to the provider because it is not included in the vital signs section of the nurse's notes. Monitoring the fetal heart rate is essential to ensure the well-being of the fetus, and any abnormalities or changes in the fetal heart rate should be promptly reported to the healthcare provider for further evaluation.
Choice D rationale:
The nurse should report the respiratory rate findings to the provider. Although the respiratory rate seems to be within the normal range (22/min at 0900 and 21/min at 1000), it is a vital sign that should be closely monitored in pregnant clients. Any sudden changes or abnormalities in the respiratory rate may indicate respiratory distress or other health issues that need medical attention. Choices E and F rationale: Deep tendon reflexes and gastrointestinal assessment findings are not mentioned in the nurse's notes or vital signs. These options are not applicable in this scenario and do not require reporting to the provider.
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