The nurse provides information to a client diagnosed with insulin-dependent diabetes mellitus. Which manifestations resulting from a blood glucose level less than 70 mg/dL (4 mmol/L) should the nurse include in the information? Select all that apply.
A. Hunger
B. Sweating
C. Weakness
D. Nervous...
A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is
prescribed to be administered before discharge. The nurse provides which information to the client
about the vaccine? Select all that apply.
1. Breast-feeding needs to be stopped for 3 months.
2. Pregnancy needs to be avoided for 1 to 3 months.
3. The vaccine is administered by the subcutaneous route.
4. Exposure to immunosuppressed individuals needs to be avoided.
5. A hypersensitivity reaction can occur if the client has an allergy to eggs.
6. The area of the injection needs to be covered with a sterile gauze for 1 week.
2. Pregnancy needs to be avoided for 1 to 3 months.
3. The vaccine is administered by the subcutaneous route.
4. Exposure to immunosuppressed individuals needs to be avoided.
5. A hypersensitivity reaction can occur if the client has an allergy to eggs.
Rubella vaccine is administered to women who have not had rubella or women who are not serologically
immune. The vaccine may be administered in the immediate postpartum period to prevent the
possibility of contracting rubella in future pregnancies. The live attenuated rubella virus is not
communicable in breast milk; breast-feeding does not need to be stopped. The client is counseled not to
become pregnant for 1 to 3 months after immunization as specified by the health care provider because
of a possible risk to a fetus from the live virus vaccine; the client must be using effective birth control at
the time of the immunization. The client should avoid contact with immunosuppressed individuals
because of their low immunity toward live viruses and because the virus is shed in the urine and other
body fluids. The vaccine is administered by the subcutaneous route. A hypersensitivity reaction can
occur if the client has an allergy to eggs because the vaccine is made from duck eggs. There is no useful
or necessary reason for covering the area of the injection with a sterile gauze.
The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV)
infection regarding care to the newborn after delivery. The client asks the nurse about the feeding
options that are available. Which response should the nurse make to the client?
1. "You will need to bottle-feed your newborn."
2. "You will need to feed your newborn by nasogastric tube feeding."
3. "You will be able to breast-feed for 6 months and then will need to switch to bottle-feeding."
4. "You will be able to breast-feed for 9 months and then will need to switch to bottle-feeding."
,1. "You will need to bottle-feed your newborn."
Perinatal transmission of human immunodeficiency virus (HIV) can occur during the antepartum period,
during labor and birth, or in the postpartum period if the mother is breast-feeding. Clients who have HIV
are advised not to breast-feed. There is no physiological reason why the newborn needs to be fed by
nasogastric tube.
A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family
remained together, holding and touching the baby. Which statement by the nurse would further assist
the family in their initial period of grief?
1. "What can I do for you?"
2. "Now you have an angel in heaven."
3. "Don't worry, there is nothing you could have done to prevent this from happening."
4. "We will see to it that you have an early discharge so that you don't have to be reminded of this
experience."
1. "What can I do for you?"
When a loss or death occurs, the nurse should ensure that parents have been honestly told about the
situation by their health care provider or others on the health care team. It is important for the nurse to
be with the parents at this time and to use therapeutic communication techniques. The nurse must also
consider cultural and religious practices and beliefs. The correct option provides a supportive, giving,
and caring response. Options 2, 3, and 4 are blocks to communication and devalue the parents' feelings.
The nurse in a maternity unit is providing emotional support to a client and her husband who are
preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by
the client indicates a component of the normal grieving process?
1. "We want to attend a support group."
2. "We never want to try to have a baby again."
3. "We are going to try to adopt a child immediately."
4. "We are okay, and we are going to try to have another baby immediately."
1. "We want to attend a support group."
A support group can help the parents work through their pain by nonjudgmental sharing of feelings. The
correct option identifies a statement that would indicate positive, normal grieving. Although the other
options may indicate reactions of the client and significant other, they are not specifically a part of the
normal grieving process.
The nurse evaluates the ability of a hepatitis B-positive mother to provide safe bottle-feeding to her
newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's
,knowledge of potential disease transmission to the newborn?
1. The mother requests that the window be closed before feeding.
2. The mother holds the newborn properly during feeding and burping.
3. The mother tests the temperature of the formula before initiating feeding.
4. The mother washes and dries her hands before and after self-care of the perineum and asks for a pair
of gloves before feeding.
4. The mother washes and dries her hands before and after self-care of the perineum and asks for a pair
of gloves before feeding.
Hepatitis B virus is highly contagious and is transmitted by direct contact with blood and body fluids of
infected persons. The rationale for identifying childbearing clients with this disease is to provide
adequate protection of the fetus and the newborn, to minimize transmission to other individuals, and to
reduce maternal complications. The correct option provides the best evaluation of maternal
understanding of disease transmission. Option 1 will not affect disease transmission. Options 2 and 3 are
appropriate feeding techniques for bottle-feeding, but do not minimize disease transmission for
hepatitis B.
The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean
delivery. Which statement made by the client indicates a need for further instruction?
1. "I will begin abdominal exercises immediately."
2. "I will notify the health care provider if I develop a fever."
3. "I will turn on my side and push up with my arms to get out of bed."
4. "I will lift nothing heavier than my newborn baby for at least 2 weeks."
1. "I will begin abdominal exercises immediately."
A cesarean delivery requires an incision made through the abdominal wall and into the uterus.
Abdominal exercises should not start immediately after abdominal surgery; the client should wait at
least 3 to 4 weeks postoperatively to allow for healing of the incision. Options 2, 3, and 4 are
appropriate instructions for the client after a cesarean delivery.
After a precipitous delivery, the nurse notes that the new mother is passive and only touches her
newborn infant briefly with her fingertips. What should the nurse do to help the woman process the
delivery?
1. Encourage the mother to breast-feed soon after birth.
2. Support the mother in her reaction to the newborn infant.
3. Tell the mother that it is important to hold the newborn infant.
4. Document a complete account of the mother's reaction on the birth record.
, 2. Support the mother in her reaction to the newborn infant.
Precipitous labor is labor that lasts 3 hours or less. Women who have experienced precipitous labor
often describe feelings of disbelief that their labor progressed so rapidly. To assist the client to process
what has happened, the best option is to support the client in her reaction to the newborn infant.
Options 1, 3, and 4 do not acknowledge the client's feelings.
The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following
a pregnancy with a placenta previa. The nurse reviews the plan of care and prepares to monitor the
client for which risk associated with placenta previa?
In placenta previa, the placenta is implanted in the lower uterine segment. The lower uterine segment
does not contain the same intertwining musculature as the fundus of the uterus, and this site is more
prone to bleeding. Options 1, 3, and 4 are not risks that are related specifically to placenta previa.
The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago.
The nurse notes that the client's temperature is 100.2° F. What is the priority nursing action?
1. Document the findings.
2. Retake the temperature in 15 minutes.
3. Notify the health care provider (HCP).
4. Increase hydration by encouraging oral fluids.
4. Increase hydration by encouraging oral fluids.
The client's temperature should be taken every 4 hours while she is awake. Temperatures up to 100.4° F
(38° C) in the first 24 hours after birth often are related to the dehydrating effects of labor. The
appropriate action is to increase hydration by encouraging oral fluids, which should bring the
temperature to a normal reading. Although the nurse also would document the findings, the
appropriate action would be to increase hydration. Taking the temperature in another 15 minutes is an
unnecessary action. Contacting the HCP is not necessary.
The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn.
The client complains to the nurse of feelings of faintness and dizziness. Which nursing action would be
most appropriate?
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