Health Promotion and Maintenance
A client with allergic rhinitis asks the nurse what to do to decrease rhinorrhea. Which instruction would be appropriate for the nurse to give the client? -"Use your nasal decongestant spray regularly to help clear your nasal passages." -"Ask the health care provider for antibiotics. Antibiotics will help decrease the secretion." -"It is important to increase your activity. A daily brisk walk will help promote drainage." -"Keep a diary of when your symptoms occur. This can help you identify what precipitates your attacks."
A: "Keep a diary of when your symptoms occur. This can help you identify what precipitates your attacks." Rationale: It is important for clients with allergic rhinitis to determine the precipitating factors so that they can be avoided. Keeping a diary can help identify these triggers. Nasal decongestant sprays should not be used regularly because they can cause a rebound effect. Antibiotics are not appropriate for allergic rhinitis because an infection is not present. Increasing activity will not control the client's symptoms; in fact, walking outdoors may increase them if the client is allergic to pollen.
An elderly couple who have just relocated to a long-term care facility have been unable to obtain a shared room. A staff member at the facility states that this should not be a concern and implies that sexual activity between the couple likely ceased many years ago. How should the nurse best respond to this individual's assertion? -"Actually it's not true that older people always stop having sexual activity when they get older." -"It's true that they've probably stopped having sexual activity but it's important for them to have companionship." -"That's true, but it's important for us to give them the teaching they need in order to resume this part of their relationship." -"Research has shown the nature of sexual activity changes with age but that it actually becomes more frequent."
A: "Actually it's not true that older people always stop having sexual activity when they get older." Rationale: Sexual activity need not be hindered by age. There is no evidence, however, that it becomes increasingly frequent in late adulthood.
A new mother is concerned because her breast-feeding neonate wants to "nurse all the time." Which response best indicates the normal neonate's breast-feeding behavior? -"Breast milk is ideal for your baby, so his stomach will digest it quickly, requiring more feedings." -"Let me call the lactation consultant to make sure that your baby is feeding properly." -"Don't worry; your baby is an aggressive feeder and needs a lot of sucking satisfaction." -"It seems as if your baby is hungry. Why don't you provide your baby with formula after the feeding to make sure the baby is getting enough nourishment?"
A: "Breast milk is ideal for your baby, so his stomach will digest it quickly, requiring more feedings." Rationale: Breast milk is the ideal food for a neonate. As a result, the neonate will digest and use all of the nutrients in each feeding quickly. Coaching the mother must include relaying this information to allay maternal concerns about producing an adequate supply of milk. Although a lactation consultant may be helpful, the nurse should be able to provide the mother with adequate information. Telling the client not to worry ignores her concern. Suggesting supplementation with formula indicates that the mother's breast-feeding attempts are unsatisfactory. Nurses shouldn't suggest giving formula to a breast-feeding neonate.
A pregnant client's labor is progressing, but her cervix is still only 5 cm dilated and 100% effaced. Although she appears relaxed, she is aware of labor contractions. At this time, which suggestion would be most helpful for the client's partner? -"Keep a record of her contraction pattern." -"Encourage her to rest between contractions." -"Suggest that she receive an epidural anesthetic." -"Have her practice rapid, shallow breathing."
A: "Encourage her to rest between contractions." Rationale: The client should be encouraged to rest as much as possible between contractions to conserve energy. In addition, the client should be encouraged to use appropriate breathing techniques, particularly slow chest breathing.Although the partner may keep track of the client's contraction pattern, this responsibility is that of the nurse caring for the client.Suggesting that she receive an epidural anesthetic is not appropriate because the client may desire natural childbirth methods.Rapid, shallow breathing or pant/blow breathing is inappropriate for this stage of labor because it can cause possible hyperventilation and lead to dizziness. This type of breathing is more appropriate for the transition stage of labor.
A boy, age 2, is diagnosed with hemophilia. The nurse explains to the father how the gene for hemophilia is transmitted. Which statement by the father indicates an understanding of gene transmission? -"Our newborn daughter may be a carrier of the trait." -"If we have more sons, all of them will have hemophilia." -"All of our offspring will carry the trait for hemophilia." -"Our daughter will develop hemophilia when she gets older."
A: "Our newborn daughter may be a carrier of the trait." Rationale: The father stating that his newborn daughter may be a carrier of the trait demonstrates understanding of X-linked recessive disorders. X-linked recessive genes behave like other recessive genes. A normal dominant gene hides the effects of an abnormal recessive gene. However, the gene is expressed primarily in male offspring because it's located on the X chromosome. Male offspring of a carrier mother and an unaffected father have a 50% chance of expressing the trait, whereas female offspring are more likely to carry the trait than express it. These parents may produce offspring who neither express nor carry the trait for hemophilia.
A 12-month-old child is seen in the neighborhood clinic for a regular checkup. Which statement by the child's mother about the influenza vaccine reflects the need for more teaching? -"Yearly influenza vaccinations are recommended to begin as early as 6 months of age." -"The Haemophilus influenzae vaccine my child has already received helps protect against some forms of the flu." -"My child is too young to receive the live attenuated intranasal vaccine." -"The first time a child receives the influenza vaccine, a second dose is recommended in 1 month."
A: "The Haemophilus influenzae vaccine my child has already received helps protect against some forms of the flu." Rationale: Haemophilus influenzae is a bacteria that can cause severe disease in children younger than age 5 years, but it does not cause influenza. Yearly vaccination for influenza is recommended to begin at 6 months. The live vaccine is not recommended for children younger than 2 years or with respiratory disease. A second vaccine 4 weeks after the first is recommended the first time a child younger than 9 years receives the flu vaccine.
The nurse is providing health screening for adolescent girls. Which of the following adolescent girls does the nurse identify as highest risk for an unplanned pregnancy? Select all that apply. -an adolescent girl living in poverty -an adolescent girl who believes in abstinence -an adolescent girl with low self-esteem -an adolescent girl with low educational achievement -an adolescent girl dating an older boy
A: -an adolescent girl living in poverty -an adolescent girl with low self-esteem -an adolescent girl with low educational achievement -an adolescent girl dating an older boy Rationale: Young women may try to use a pregnancy to escape a poor living situation. Those with low education and literacy levels may not possess the knowledge or information needed to protect themselves from unwanted pregnancies. A young woman with low self-esteem may be pressured into a sexual relationship, especially when involved with an older boy, resulting in an unwanted pregnancy. Rationale: Young women may try to use a pregnancy to escape a poor living situation. Those with low education and literacy levels may not possess the knowledge or information needed to protect themselves from unwanted pregnancies. A young woman with low self-esteem may be pressured into a sexual relationship, especially when involved with an older boy, resulting in an unwanted pregnancy.
The mother of an infant with iron deficiency anemia asks the nurse what she could have done to prevent the anemia. The nurse should teach the mother that it is helpful to introduce solid foods into the infant's diet at which age? -3 months -6 months -8 months -10 months
A: 6 months Rationale: Solids should be introduced at 6 months. Full-term infants use up their prenatal iron stores within 4 to 6 months after birth. Milk contains insufficient iron.
The nurse notes a client has produced 1700 mL of dilute urine in the 12-hour period following cesarean birth. What action would the nurse take based on this finding? -Document the finding, and complete routine postpartum assessment. -Request kidney function tests including creatinine and urea levels. -Assess the protein level of the urine using a dipstick at the bedside. -Elevate the client's legs on two pillows, and restrict fluid intake.
A: Document the finding, and complete routine postpartum assessment. Rationale: It is normal for the client to experience diuresis in the first 24 hours after birth (whether vaginal or cesarean). An amount of 3 liters in 24 hours is not unusual. Also, the client will have received IV fluids during labor, which increases input significantly. There is no indication of kidney dysfunction. If preecamplia is suspected, urine output would be decreased, not increased; this makes testing for protein unwarranted. The client may have edema present, for which elevating the legs can encourage further diuresis, but there is not reason to restrict fluid intake.
A parent of a 2-year-old child states the child cries when being dropped off at daycare but seems happy when being picked up later in the day. What is the best advice the nurse can give the parent related to this behavior? -"This is a normal stage of development that toddlers go through." -"Your child is likely afraid of something at the daycare." -"Send your chilld's favorite toy to daycare as a comfort object." -"It would help if you make a game of going to daycare."
A: "This is a normal stage of development that toddlers go through." Rationale: Separation anxiety starts as early as 5 months old and is most evident in toddlers and preschoolers. It occurs after the child has gained an understanding of object permanence. Once the toddler learns the parent is really gone, crying and temper tantrums ensue. Because the toddler has a short attention span, once their attention is diverted to another activity the anxiety is reduced. Taking a favorite toy or blanket with the child may be helpful but does not solve the child's anxiety. It might be good for the parent to discuss the situation with the daycare personnel, but it still does not prevent the child from having separation anxiety.
The nurse is providing discharge instructions to a client newly diagnosed with the hepatitis C virus (HCV). When evaluating the teaching, which statement made by the client indicates a need for further teaching? Select all that apply. -"I will make sure that my family has had the vaccine against hepatitis C." -"I will not share my personal items such as toothbrush or razor with others." -"Having an occasional alcoholic beverage will not be a problem." -"I know I get tired easily. I will rest periodically throughout the day." -"I realize that epigastric pain is a symptom of my liver growing."
A: -"I will make sure that my family has had the vaccine against hepatitis C." -"Having an occasional alcoholic beverage will not be a problem." Rationale: The Centers for Disease Control (CDC) has released a 2017-2020 National Viral Hepatitis Action Plan to prevent new infections and improve the lives of those with the chronic disease. Hepatitis C is the most common chronic liver disease. Hepatitis C clients may have no symptoms until later stages of the disease. There is no vaccine for the disease ,which leaves the clients fatigued after minimal exertion. Periods of rest are needed throughout the day. The primary mode of transmission is through blood exposure such as through bleeding from the oral mucosa or blood on razors. Meticulous care to prevent cross contamination is needed. Epigastric pain is a common symptom due to the enlarging liver. A client should not have alcoholic beverages due to the impact on the liver.
A nurse is preparing to teach a client about fetal growth and development during the first 3 months of pregnancy. The nurse is assembling teaching aids by milestones. In ascending order, (month 1, month 2, month 3, and months 4 to 9), how would the nurse arrange the aids? All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1 The embryo has a definite form; the head, trunk, and tiny buds for arms and legs develop; and the cardiovascular system begins to function. 2 The eyes, ears, nose, lips, tongue, and tooth buds develop; the umbilical cord has a definite form; and the external genitalia are present. 3 Teeth and bones begin to appear, the kidneys start to function and, at the end of the month, gender is distinguishable. 4 Internal and external fetal growth continues at a rapid rate, and the fetus stores the fats and minerals it needs to live outside the womb.
A: -The embryo has a definite form; the head, trunk, and tiny buds for arms and legs develop; and the cardiovascular system begins to function. -The eyes, ears, nose, lips, tongue, and tooth buds develop; the umbilical cord has a definite form; and the external genitalia are present. -Teeth and bones begin to appear, the kidneys start to function and, at the end of the month, gender is distinguishable. -Internal and external fetal growth continues at a rapid rate, and the fetus stores the fats and minerals it needs to live outside the womb. Rationale: Significant growth and development take place during the first 3 months. By the first month, the embryo has a definite form; the head, trunk, and tiny buds for arms and legs develop; and the cardiovascular system begins to function. By the second month, the eyes, ears, nose, lips, tongue, and tooth buds develop; the umbilical cord has a definite form; and the external genitalia are present. By the third month, teeth and bones begin to appear; the kidneys start to function and; at the end of the month, gender is distinguishable. By the fourth month, internal and external fetal growth begins accelerating at a more rapid rate; the fetus stores the fats and minerals it needs to live outside the womb; and growth continues until the fetus is full term.
Which intervention would be most appropriate to institute when a school-age child with burns becomes angry and combative when it is time to change the dressings and apply mafenide acetate? -Ensure parental support during the dressing changes. -Allow the child to assist in removing the dressings and applying the cream. -Give the child permission to cry during the procedure. -Allow the child to schedule the time for dressing changes.
A: Allow the child to assist in removing the dressings and applying the cream. Rationale: Expressions of anger and combativeness are often the result of loss of control and a feeling of powerlessness. Some control over the situation is regained by allowing the child to participate in care. Although having parental support during the dressing changes may be helpful, this action does nothing to allow the child control. Giving the child permission to cry may help with verbalizing feelings, but doing so does nothing to provide the child with control over the situation. Although allowing the child to determine the time for dressing changes may provide a sense of control over the situation, doing so is inappropriate because the dressing changes need to be performed as prescribed to ensure effectiveness and healing.
A 42-year-old female is interested in making dietary changes to reduce her risk of colon cancer. What dietary selections should the nurse suggest? -croissant, granola and peanut butter squares, whole milk -bran muffin, skim milk, stir-fried broccoli -granola, bagel with cream cheese, cauliflower salad -oatmeal-raisin cookies, baked potato with sour cream, turkey sandwich
A: bran muffin, skim milk, stir-fried broccoli Rationale: High-fiber, low-fat diets are recommended to reduce the risk of colon cancer. Stir-frying, poaching, steaming, and broiling are all low-fat methods to prepare foods. Croissants are made of refined flour. They are also high in fat, as are peanut butter squares, whole milk, granola, cream cheese, and sour cream.
According to Erikson's theory of development, chronic illness can interfere with which stage of development in an 11-year-old child? -intimacy versus isolation -trust versus mistrust -industry versus inferiority -identity versus role confusion
A: industry versus inferiority Rationale: According to Erikson, an 11-year-old child is working through the stage of industry versus inferiority. Chronic illness may interfere with this stage of development in an 11-year-old child because the child may not be able to accomplish tasks, which prevents the child from achieving a sense of industry. Intimacy is the developmental task of a young adult. Trust is the developmental task to be achieved during infancy. Identity is the developmental task of adolescence.
After conducting a presentation to a group of adolescent parents on the topic of adolescent pregnancy, the nurse determines that one of the parents needs further instruction when the parent says that adolescents are at greater risk for which complication? -denial of the pregnancy -low-birth-weight infant -cephalopelvic disproportion -congenital anomalies
A: congenital anomalies Rationale: Additional teaching is needed when the parent says that adolescents are at greater risk for congenital anomalies. Although adolescents are at greater risk for denial of the pregnancy, lack of prenatal care, low-birth-weight infant, cephalopelvic disproportion, anemia, and nutritional deficits and have a higher maternal mortality rate, studies reveal that congenital anomalies are not more common in adolescent pregnancies.
Which client is most likely to develop systemic lupus erythematosus (SLE)? -a 25-year-old white male -a 25-year-old Jewish female -a 27-year-old black female -a 35-year-old Asian male
A: a 27-year-old black female Rationale: SLE strikes nearly 10 times as many women as men and is most common in women between ages 15 and 40. SLE affects more black women than white women; its incidence is about 1 in every 250 black women, compared to 1 in every 700 white women.
A nurse caring for a preterm neonate knows that positioning can benefit high-risk neonates. Which position is appropriate for a preterm neonate? -hyperabduction and extension of the arms with external rotation of the hips -neck extension and back arching with flattened shoulders -adduction and flexion of the extremities with gently rounded shoulders -abduction and flexion of the arms with flattened shoulders
A: adduction and flexion of the extremities with gently rounded shoulders Rationale: The goal of neonatal positioning is to gently round shoulders and flex elbows and to avoid abduction of the shoulders and hips. This positioning enhances physiologic stability and developmental progress. Hyperabduction and external rotation in a preterm neonate may result in contractures. Neck extension, back arching, flattened shoulders, and abduction should be avoided in neonates.
A client has just expelled a hydatidiform mole. She's visibly upset over the loss and wants to know when she can try to become pregnant again. How should the nurse respond? -"Why don't we discuss this with you at a later time when you're feeling better." -"You must wait at least 1 year before becoming pregnant again." -"Let me check with your physician and get you something that will help you relax." -"Pregnancy should be avoided until all of your testing is normal."
A: "You must wait at least 1 year before becoming pregnant again." Rationale: Clients who develop a hydatidiform mole must be instructed to wait at least 1 year before attempting another pregnancy, despite testing that shows they have returned to normal. A hydatidiform mole is a precursor to cancer, so the client must be monitored carefully for 1 year by an experienced health care provider. Discussing this situation at a later time or checking with the physician to give the client something to relax does nothing to address the client's immediate concerns. Advising the client to wait until all tests are normal is a vague response and provides the client with little information.
The nurse is preparing to assess a toddler's heart and lung sounds. Which of the following actions is most important for the nurse to take to obtain an accurate assessment? -Ensure that the child does not cry. -Place the child in a sitting position. -Explain the procedure to the child. -Verify the correct size of the equipment.
A: Ensure that the child does not cry. Rationale: It is extremely difficult to auscultate and evaluate heart and lung sounds in a crying child. The toddler is old enough to understand placing the stethoscope on the chest. The nurse should allow the toddler to play with the stethoscope and be involved so that the assessment can be completed. The child can sit or lie to assess the lung and heart sounds. The size of the equipment does not require verification.
Which approach by a nurse is the best for trying to take a crying toddler's temperature? -Ignore the crying and screaming. -Tell the caregiver not to hold the client. -Talk to the caregiver first and then to the client. -Bring extra help so it can be done quickly.
A: Talk to the caregiver first and then to the client. Rationale: When dealing with a crying client, the best approach is to talk to the caregiver first then to the toddler. This approach helps the client get used to the nurse before attempting any procedures. It also gives the client an opportunity to see that the caregiver trusts the nurse. Ignoring the crying and screaming may be the second step. The nurse should encourage the caregiver to hold the client because it will likely help the situation. The last resort is to bring in assistance so the procedure can be completed quickly.
Which intervention would be least appropriate for a client who is in a double hip spica cast? -encouraging the intake of cranberry juice -advising the client to eat large amounts of cheese -establishing regular times for elimination -having the client dangle at the bedside
A: advising the client to eat large amounts of cheese Rationale: The client in a double hip spica cast should avoid eating foods that can be constipating, such as cheese. Rather, fresh fruits and vegetables should be encouraged, and the client should be encouraged to drink at least 2,500 mL/day. Drinking cranberry juice, which helps keep urine acidic, thereby avoiding the development of renal calculi, is encouraged. The client should be encouraged to establish regular times for elimination to promote regularity in bowel and bladder habits. The client will develop orthostatic hypotension unless the circulatory system is reconditioned slowly through dangling and standing exercises.
Assessment of a primigravid client in active labor who has had no analgesia or anesthesia reveals complete cervical effacement, dilation of 8 cm, and the fetus at 0 station. The nurse should expect the client to exhibit which behavior during this phase of labor? -excitement -loss of control -numbness of the legs -feelings of relief
A: loss of control Rationale: Assessment findings indicate that the client is in the transition phase of labor. During this phase, it is not unusual for clients to exhibit a loss of control or irritability. Leg tremors, nausea, vomiting, and an urge to bear down also are common. Excitement is associated with the latent phase of labor. Numbness of the legs may occur when epidural anesthesia has been given; however, it is rare when no anesthesia is given. Feelings of relief generally occur during the second stage, when the client begins bearing-down efforts.
During a childbirth preparation class, a primigravid client at 36 weeks' gestation tells the nurse, "My lower back has really been bothering me lately." Which exercise suggested would be most helpful? -pelvic rocking -deep breathing -tailor sitting -squatting
A: pelvic rocking Rationale: Pelvic rocking helps to relieve backache during pregnancy and early labor by making the spine more flexible. Deep breathing exercises assist with relaxation and pain relief during labor. Tailor sitting and squatting help stretch the perineal muscles in preparation for labor.
The inability of an 18-month-old child to perform what activity would cause the nurse to be concerned? -copying a circle -playing with pull toys -playing tag with other children -building a tower of eight blocks
A: playing with pull toys Rationale: Playing with pull toys is a typical task of a normally developed 18-month-old child. Inability of the toddler to do so would be a concern.Copying a circle and building a tower of eight or more blocks is a behavior typical of a 3-year-old child.Playing tag with other children requires cooperative play and the ability to follow rules; this behavior develops at about age 5 years.
During a routine otoscopic examination the nurse identifies these assessment changes. Which finding requires additional action? -visualization of the ossicles through the tympanic membrane -fine hairs in the auditory canal with dark brown wax -light reflecting off the ear drum surface -reddened tympanic membrane without discomfort
A: reddened tympanic membrane without discomfort Rationale: To perform an otoscopic examination on an adult, the nurse grasps the auricle of the ear and pulls it up and back to straighten the ear canal. For a child, the nurse grasps the auricle and pulls it down to straighten the ear canal. Normal findings should include visualization of the ossicles through the tympanic membrane, fine hairs in the auditory canal with wax, and reflection of light off the light-gray or pearly white shiny ear drum. A reddened ear drum would indicate an infection with our without pain.
A parent asks the nurse what types of activities the 3-year-old child should be able to do at this age. What is the nurse's best response? -ride a tricycle -lace shoelaces -throw ball overhand -jump rope
A: ride a tricycle Rationale: The nurse should expect the child to ride a tricycle because at age 3 gross motor development and refinement in eye-hand coordination enable a child to perform such an action. The fine motor skills required to lace shoelaces and the gross motor skills required for throwing a ball overhanded and jumping rope develop around age 4.
Two hours ago, examination of a multigravid client in labor without anesthesia revealed the following: cervical dilation at 5 cm with complete effacement, presenting part at 0 station, and membranes intact. The nurse caring for the client now observes that the client feels a strong need to have a bowel movement. What is the client most likely experiencing? -a precipitous labor pattern -fear and anxiety related to the labor outcome -spontaneous rupture of the membranes -the second stage of labor
A: the second stage of labor Rationale: The urge to have a bowel movement, bear down, and push are all signs that the client is beginning the second stage of labor that occurs when the client is 10-cm dilated. A multigravid client generally progresses more rapidly than a primigravid client does. Therefore, it would not be unusual for a client's cervix to dilate from 5 to 10 cm or more within a 2-hour period.No evidence is presented that the client is experiencing a precipitous labor pattern, which would be evidenced by rapid cervical dilation.No evidence is presented that the client is experiencing fear and anxiety related to the labor outcome.Spontaneous rupture of the membranes, evidenced by a sudden gush of fluid, may occur at any time in the labor process.
When examining a client who has abdominal pain, a nurse should assess -any quadrant first. -the symptomatic quadrant first. -the symptomatic quadrant last. -the symptomatic quadrant either second or third.
A: the symptomatic quadrant last. Rationale: The nurse should systematically assess all areas of the abdomen, if time and the client's condition permit, concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the symptomatic area, causing the muscles in other areas to tighten. This tightening would interfere with further assessment.
The primary goal for the client with Buerger's disease is to prevent: -embolus formation. -fat embolus formation. -thrombus formation. -thrombophlebitis.
A: thrombus formation. Rationale: Because of the inflammation, a common complication of Buerger's disease is thrombus formation and potential occlusion of the vessel. Inflammation of the immediate and small arteries and veins is involved in the disease process. Embolus is a potential risk if a thrombus has developed. Fat embolus is associated with fractures of the bones. Thrombophlebitis occurs after thrombus formation.
A client arrives for an annual physical examination. During the history, the client reports recurrent symptoms of heartburn, a sour taste in the mouth, and hoarseness in the throat. In anticipation of client teaching, illustrate on the diagram the location of the structure which frequently enables these symptoms to occur.
A/Rationale: The lower esophageal sphincter is a ring of muscle fibers that prevents food from moving backward from the stomach into the esophagus. If this sphincter does not close well, food, fluids, and stomach contents can irritate and even damage the esophagus. Symptoms include heartburn, a sour taste in the mouth, hoarseness, dysphagia, and feelings of a lump in the throat.
A healthy client presents to the clinic for a routine examination. When auscultating the client's lower lung lobes, the nurse should expect to hear which type of breath sound? -bronchial -tracheal -vesicular -bronchovesicular
A: vesicular Rationale: Vesicular breath sounds are soft, low-pitched sounds normally heard over the lower lobes of the lung. They're prolonged on inhalation and shortened on exhalation. Bronchial breath sounds are loud, high-pitched sounds normally heard next to the trachea; discontinuous, they're loudest during expiration. Tracheal breath sounds are harsh, discontinuous sounds heard over the trachea during inhalation or exhalation. Bronchovesicular breath sounds are medium-pitched, continuous sounds that occur during inhalation or exhalation. They're best heard over the upper third of the sternum and between the scapulae.
Twenty-four hours after a client has given birth, the nurse documents that involution is progressing normally after palpating the client's fundus at which location? -slightly below the level of the umbilicus -midway between the umbilicus and the symphysis pubis -barely above the upper margin of the symphysis pubis -slightly above the level of the umbilicus
A: slightly below the level of the umbilicus Rationale: Approximately 24 hours after childbirth, the height of the uterus is normally felt slightly below the umbilicus. Unless complications occur, this client can expect the fundus to descend at a rate of about 1 fingerbreadth per day.Immediately after childbirth, the top of the fundus normally is midway between the umbilicus and the symphysis pubis.The fundus is barely palpable above the upper margin of the symphysis pubis 7 to 10 days after childbirth.Palpation of the uterus above the umbilicus may indicate urinary retention or retained placental fragments.
The parent of a 9-month-old expressed concern that the baby "is developing slowly." The nurse is concerned about a developmental delay when finding the baby is unable to accomplish which skill? -vocalizing single syllables -standing alone -building a tower of two cubes -drinking from a cup with little spilling
A: vocalizing single syllables Rationale: Normally, a 9-month-old infant should have been voicing single syllables since 6 months of age. Absence of this finding would be a cause for concern. An infant usually is able to stand alone at about 10 months of age. An infant usually is able to build a tower of two cubes at about 15 months of age. An infant usually is able to drink from a cup with little spilling at about 15 months of age.
A client in the first trimester of pregnancy joins a childbirth education class. During this trimester, the class is most likely to cover which physiologic aspect of pregnancy? -signs and symptoms of labor -quickening and fetal movements -warning signs of complications -false labor and true labor
A: warning signs of complications Rationale: In early childbirth education classes, instruction on the physiologic aspects of pregnancy may include warning signs of complications, the anatomy and physiology of pregnancy, nutrition, and fetal development. Signs and symptoms of labor, quickening and fetal movements, and false and true labor are usually discussed in later classes.
