The nurse has been assigned a client who delivered a 6- lb, 12-oz baby boy vaginally 40 minutes ago. The initial assessment of greatest importance for this client would be:
Answer(s): D
The length of labor has little bearing on the fourth stage of labor. The type of labor and delivery is significant. (B) The type of episiotomy will affect the client's comfort level. However, the nurse's assessment and implementations center on prevention of hemorrhage during the fourthstage of labor. The amount of bleeding from the episiotomy or hematoma formation is of higher priority than the type of episiotomy. (C) The amount of IV fluid to be infused is a nursing function to be attended to; however, it is lower in priority than determining if hemorrhaging is occurring. (D) Character of the fundus would be the priority nursing assessment because changes in uterine tone may identify possible postpartum hemorrhage.
Parents of young children often need anticipatory guidance from the nurse. Parents may have little knowledge regarding growth and development. Which of the following toys and activities would the nurse suggest as appropriate for a toddler?
Answer(s): C
(A) These activities are suited for the preschool-age child (35 years old). The activities are not safe for a toddler. (B) Infants (01 year) like these toys. (C) These activities provide the toddler (13 years old) with a variety of physical activities for play. (D) The toddler lacks the physical and cognitive abilities for these activities. The tasks are far better suited for the school-age child.
A client was exhibiting signs of mania and was recently started on lithium carbonate. She has no known physical problems. A teaching plan for this client would include which of the following?
Answer(s): A
(A) This answer is correct. A balanced diet with adequate salt intake is necessary. (B) This answer is incorrect. The client must drink six to eight full glasses of fluid per day (20003000 mL/day). (C) This answer is incorrect. The client should be instructed to avoid fluctuations of sodium intake. Diet should be balanced, with an adequate salt intake. (D) This answer is incorrect. Nausea is a frequent side effect that can be minimized with administration of drug with meals or after eating food.
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