The teaching plan for a postpartum client who is about to be discharged should include which of the following instructions?
Answer(s): D
The vaginal discharge after birth is called lochia, and it changes from red (rubra) to serosa (clear) on the third postpartum day. If it returns to red or contains clots, it could signal impending hemorrhage or infection and the physician should be notified.It is not normal for the breasts to be tender. If the breasts become engorged, they might be tender and the mother might need to be given additional instructions on breast care. Tenderness, redness, and fatigue are clinical manifestations of mastitis and should be reported to the physician.A woman should void in normal patterns and frequency after birth. Increased frequency is a sign of a urinary tract infection and should be reported to the physician.By the time of discharge, the woman’s temperature should be normal. Elevations should be reported to the physician.
The parents of a 2-year-old child ask the nurse how they can teach their child to quit taking toys away from other children.Which of the following statements by the nurse offers the parents the best explanation of their child’s behavior?
Answer(s): A
Two-year-old children are very egocentric. They believe everything and everyone is concerned about them. They believe other children want them to have their toys. This is different than believing they can make other children want them to have all the toys, as in magical thinking, which normally occurs in preschool-age children.Toddlers are very negative, but this is expressed by refusal of requests made to them.Domestic imitation does occur in preschool-age children, but it refers to the imitation of household chores and roles performed by adults, not the imitation of other children.
Which of the following infant behaviors demonstrates the concept of object permanence?
Answer(s): B
Object permanence occurs when the infant learns that something/someone still exists even though they might not be able to see it/them. This develops between 9 and 10 months of age. If the infant cries when his mother leaves the room, it might be because he believes she is no longer in the house when he can’t see her. If an infant picks up another toy after the one he is playing with rolls under the couch and the infant fails to look for it, he believes the toy that rolled under the couch no longer exists.Patty-cake is a game infants engage in but, it has nothing to do with object permanence.An infant game that does show object permanence is peek-a-boo. In this game, an infant continues to hunt for a hidden face because he believes it is still there.
Which of the following home-care strategies is most likely to negatively impact the body image of a client with Cushing’s syndrome?
Answer(s): C
All of the strategies listed are included in home care for the client with Cushing’s syndrome. Choice “wearing a medical ID indicating Cushing’s syndrome” is the best answer because wearing a medical ID is a visible sign that something is wrong and a constant reminder to the client that he or she has a loss of body function.Choice “providing safety measures to prevent falls” might enhance body image because it prevents falls that could cause further injury and debilitation.Taking medications as prescribed should enhance body image because it decreases the symptoms present. Having regular health assessments indicates an enhanced body image because it signals the desire to take care of the body and keep it at its best.
When a client who is 25 years of age asks the nurse when she should seek fertility counseling, the best response by the nurse is ______________.
The guidelines for a fertility workup are to refer after the couple has not conceived after one year of unprotected intercourse. So, Choice “Fertility counseling should be sought when you have been unable to conceive after 1 year of unprotected intercourse.” is technically correct, but it doesn’t consider the immediate need for the couple to have some counseling.Choice “We can give you some guidance now on how to increase your chances of conceiving and then refer you if it doesn’t happen within a year.” is the best answer because it gives the couple guidance now and the referral at the appropriate time.If the woman is over the age of 35, an earlier referral, at six to nine months of unprotected intercourse, is appropriate. It is true that the average time it takes a 25-year-old woman to conceive is 5.3 months, but that does not address the concern the client is expressing. Choice “We can give you some guidance now on how to increase your chances of conceiving and then refer you if it doesn’t happen within a year.” is still the most caring and correct answer.Couples conceive within the first month of unprotected intercourse 20% of the time.
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