A nurse is caring for a client who is postpartum, has a deep-vein thrombosis, and is receiving heparin therapy via subcutaneous injections. Which of the following actions should the nurse take?

Request a prescription for PRN aspirin from the provider.

Massage the injection site thoroughly following administration.

Instruct the client that they cannot breastfeed while receiving heparin.

Administer the injection in the client's abdomen.

Answer and Explanation

The Correct Answer is D

Choice A reason:

Requesting a prescription for PRN aspirin is incorrect because aspirin is an antiplatelet agent and should not be combined with heparin without specific medical advice due to the increased risk of bleeding.

Choice B reason:

Massaging the injection site is not recommended as it can cause trauma to the tissue and increase the risk of bleeding, which is especially concerning in a patient with deep-vein thrombosis.

Choice C reason:

Instructing the client that they cannot breastfeed while receiving heparin is incorrect. Heparin does not pass into breast milk in significant amounts and is considered safe for use while breastfeeding.

Choice D reason:

Administer the injection in the client's abdomen. Heparin is typically administered subcutaneously in the abdomen to ensure proper absorption and minimize discomfort. Because it is an area with large amounts of subcutaneous fat

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Correct Answer is D

Explanation

Choice A rationale:

The clinical finding of 0 station does not provide information about the fetal head's position in the left occiput posterior position. Station refers to the level of the presenting part in relation to the ischial spines, not the position.

Choice B rationale:

The clinical finding of 0 station does not indicate that the largest fetal diameter has passed through the pelvic outlet. The station only tells us the level of the presenting part and does not provide information about the diameter passing through the pelvic outlet.

Choice C rationale:

The clinical finding of 0 station does not directly involve the palpability of the posterior fontanel. Station is determined based on the level of the presenting part in the birth canal.

Choice D rationale:

This is the correct interpretation of the clinical finding. 0 station means that the presenting part (usually the baby's head) is at the level of the ischial spines, which serves as a reference point during labor. As labor progresses and the baby moves further down the birth canal, the station becomes more negative (e.g., -1, -2) until delivery occurs.

A. "I will leave the diaphragm in place for 4 hours following intercourse.” B. "I will remove the diaphragm by catching the rim below the dome with my forefinger.” C. "I will place a thin layer of mineral oil on the diaphragm once per week.” D. "I will place 2 teaspoons of spermicide on the inside of the diaphragm before inserting it.”

Correct Answer is D

Explanation

Choice A rationale:

Leaving the diaphragm in place for 4 hours following intercourse is incorrect. The diaphragm should be left in place for at least 6 hours after intercourse to ensure effectiveness in preventing pregnancy.

Choice B rationale:

Removing the diaphragm by catching the rim below the dome with the forefinger is incorrect. The diaphragm should be removed by hooking the finger behind the rim to avoid damaging the dome and ensure proper removal.

Choice C rationale:

Placing a thin layer of mineral oil on the diaphragm once per week is incorrect. Mineral oil can weaken latex diaphragms, reducing their effectiveness. Water-based lubricants are recommended for use with diaphragms.

Choice D rationale:

Placing 2 teaspoons of spermicide on the inside of the diaphragm before insertion is the correct technique. Spermicide helps to immobilize and kill sperm, enhancing the contraceptive effect of the diaphragm.

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A nurse is caring for a client who is postpartum, has a deep-vein thrombosis, and is receiving heparin therapy via subcutaneous injections. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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