A nurse is assessing a client two weeks postpartum. Which of the following statements by the client indicates a need for further evaluation?

"I really wish I had a girl instead."

"I am so relieved the baby looks like my mother."

"My labor was so long I'm glad it's over."

"My appetite has really increased”

Answer and Explanation

The Correct Answer is A

A. "I really wish I had a girl instead.": Expressing disappointment in the baby's gender may indicate difficulty bonding with the infant or potential postpartum emotional concerns. This statement warrants further evaluation to assess for postpartum depression or attachment issues.

B. "I am so relieved the baby looks like my mother.": Feeling relieved that the baby resembles a family member is a normal emotional reaction and does not typically require further psychological evaluation unless associated with more concerning behaviors.

C. "My labor was so long I'm glad it's over.": Expressing relief after a long labor is a normal reaction and does not indicate emotional distress or dysfunction that would need further mental health evaluation.

D. "My appetite has really increased.": An increased appetite two weeks postpartum is a normal physiological response as the body recovers from childbirth, particularly if the client is breastfeeding. It does not suggest a need for further emotional or physical evaluation.

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Correct Answer is B

Explanation

A. "We will switch our baby's car seat to forward-facing when they turn one.": Current guidelines recommend keeping infants and toddlers in a rear-facing car seat until they reach the maximum height or weight limit of the seat, often well past one year, to provide optimal protection in a crash.

B. "We will check the temperature of the car seat surface before placing our baby in the seat when it is hot out.": This statement shows good understanding. Car seat surfaces can become dangerously hot and cause burns. Checking the seat temperature ensures the baby’s safety and comfort before securing them inside.

C. "We will make sure to activate the air bag when we place the car seat in the front passenger seat.": Airbags can cause serious injury or death to infants in rear-facing car seats. Car seats should always be placed in the back seat, and airbags should be deactivated if absolutely necessary to place a seat in the front, which is discouraged.

D. "We will wrap our baby in a blanket under the car seat straps when it is cold out.": Placing a blanket under the straps can prevent the harness from fitting snugly and securely. Instead, the harness should be fastened correctly first, and then a blanket can be placed over the baby for warmth.

A. Administer aspirin for fever B. Apply cooling blanket C. Monitor vital signs every 4 hours D. Place client on telemetry E. Palpate thyroid area to assess for hematoma

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

• Apply cooling blanket: The client has an elevated temperature (38.3°C/100.9°F), which could suggest early signs of thyroid storm, a life-threatening complication after thyroid surgery. Applying a cooling blanket is an appropriate non-pharmacological intervention to help manage hyperthermia without medications that could worsen symptoms.

• Monitor vital signs every 4 hours: Frequent monitoring of vital signs is critical after thyroidectomy to detect early signs of complications such as thyroid storm, hemorrhage, or airway compromise. Vital sign changes can provide early warning signs of clinical deterioration and allow for rapid intervention.

• Place client on telemetry: Thyroid storm and other thyroid-related crises can cause arrhythmias, including tachycardia and atrial fibrillation. Continuous cardiac monitoring is anticipated to quickly detect and manage any rhythm disturbances that may arise postoperatively.

• Palpate thyroid area to assess for hematoma: After a thyroidectomy, it is essential to assess for hematoma formation, as hematomas can compress the airway and become life-threatening. Regular palpation of the surgical site helps detect swelling, firmness, or respiratory distress early.

• Administer aspirin for fever: Aspirin is not recommended for fever management in postoperative thyroidectomy clients because it can displace thyroid hormones from binding proteins, potentially worsening thyrotoxicosis. Fever should be managed with other antipyretics like acetaminophen or physical cooling methods instead.

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A nurse is assessing a client two weeks postpartum. Which of the following statements by the client indicates a need for further evaluation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching to the parents of an infant about the correct use of infant car seats. Which of the following statements by the parents indicates an understanding of the teaching?

Correct Answer is B

Explanation

The nurse has reviewed the Vital Signs at 1000. For each potential provider prescription, click to specify if the prescription is anticipated or non-anticipated for the client.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

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