A nurse is planning care for a postpartum client who expresses a desire to follow the traditional beliefs regarding the balance of yin and yang for postpartum care.
Which of the following actions should the nurse plan to take?

Apply a new ice pack to the client's perineal area every 4 hours.

Maintain a cool environment in the client's room.

Provide the client with a warm beverage.

Assist the client with showering twice daily.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Applying ice packs aligns with Western medical practices for reducing swelling and pain. However, traditional yin and yang beliefs often emphasize warmth during the postpartum period to restore a perceived loss of "hot" energy after childbirth. Cold applications could be seen as counterproductive to this balance.

Choice B rationale

Maintaining a cool environment would contradict the traditional belief in maintaining warmth for the postpartum client. In many cultures, a "hot-cold" theory dictates that the postpartum period is a "cold" state, requiring warmth to restore balance and prevent illness. A cool room would be perceived as harmful.

Choice C rationale

Providing a warm beverage aligns with traditional yin and yang postpartum care. Childbirth is often seen as a significant loss of "yang" energy (warmth, activity). Consuming warm foods and beverages helps to replenish this energy, promoting restoration of balance and preventing "cold" illnesses according to this belief system.

Choice D rationale

Showering twice daily, especially with cool water, might conflict with traditional postpartum practices that often restrict bathing or emphasize warm baths. The concern is often about preventing "cold" from entering the body and disrupting the balance, as well as conserving energy during a vulnerable period.

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Correct Answer is ["A","B","C"]

Explanation

Choice A rationale: The client exhibits signs consistent with severe preeclampsia including blood pressure above 160/110 mm Hg, 3+ to 4+ deep tendon reflexes, and positive clonus, which are neurological indicators of central nervous system irritability. These findings increase the risk for eclamptic seizures. The headache, visual disturbances (“spots”), and epigastric pain further indicate imminent seizure risk from cerebral edema and vasospasm. Early intervention is crucial to prevent progression to eclampsia.

Choice B rationale: Elevated blood pressure combined with preeclampsia significantly raises the risk of abruptio placentae, the premature separation of the placenta from the uterine wall. This occurs because hypertension causes vasospasm and weakening of the placental attachment, increasing placental insufficiency and hemorrhage. The client’s edema and headache indicate vascular endothelial dysfunction, contributing to this risk. Abruptio placentae is a critical obstetric emergency requiring urgent recognition.

Choice C rationale: The client’s symptoms and signs of hypertension, headache, epigastric pain, and elevated blood pressure with edema suggest progression toward HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets). Although labs are not provided, the clinical presentation fits the syndrome’s prodromal phase. HELLP syndrome is a severe variant of preeclampsia with hepatic involvement, which can cause multiorgan dysfunction and increased maternal-fetal morbidity if untreated.

Choice D rationale: Polyuria, or excessive urine output, is not typical in preeclampsia or related hypertensive disorders; instead, oliguria (decreased urine output below 30 mL/hr) may occur due to renal impairment. The client’s urine output of 25–55 mL/hr borders low normal, signaling possible kidney hypoperfusion, but polyuria is not a recognized complication here. Polyuria is more associated with diabetes or diuretic therapy, not hypertensive pregnancy disorders.

Choice E rationale: Ketoacidosis is metabolic acidosis due to ketone accumulation from uncontrolled diabetes or starvation. This client has no history or symptoms of diabetes or starvation, and no laboratory evidence of hyperglycemia or acidosis is reported. Ketoacidosis is not a complication linked to preeclampsia or hypertension in pregnancy and is therefore unlikely in this case.

Choice F rationale: Fetal macrosomia is excessive fetal growth usually related to maternal diabetes or obesity. This client has no indications of gestational diabetes or excessive fetal growth; fetal heart rate and contractions are within normal limits, and no mention of abnormal fundal height or ultrasound findings is given. The mild hypertension and edema do not predispose to macrosomia.

A. Consuming 27 mg of iron daily. B. Consuming 300 mg of caffeine daily. C. Consuming 3 L (101 oz) of water daily. D. Consuming 400 mcg of folate daily.

Correct Answer is B

Explanation

Choice A rationale

Consuming 27 mg of iron daily is within the recommended intake for pregnant individuals, which is typically around 27 mg per day. Iron is crucial for fetal growth and preventing maternal anemia, and this intake level supports healthy pregnancy outcomes, indicating a reduced risk factor.

Choice B rationale

Consuming 300 mg of caffeine daily is considered a high-risk lifestyle factor during pregnancy. High caffeine intake is associated with an increased risk of miscarriage, preterm birth, and low birth weight infants. The recommended limit for pregnant individuals is generally below 200 mg per day to mitigate these risks.

Choice C rationale

Consuming 3 L (101 oz) of water daily is a healthy practice during pregnancy. Adequate hydration is essential for maintaining blood volume, amniotic fluid levels, and preventing constipation and urinary tract infections. This intake level supports maternal and fetal health.

Choice D rationale

Consuming 400 mcg of folate daily is the recommended intake for pregnant individuals, particularly in the periconceptional period. Folic acid supplementation significantly reduces the risk of neural tube defects in the fetus, promoting a healthy pregnancy outcome and indicating a reduced risk factor.

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A nurse is planning care for a postpartum client who expresses a desire to follow the traditional beliefs regarding the balance of yin and yang for postpartum care. Which of the following actions should the nurse plan to take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","B","C"]

Explanation

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Explanation

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A nurse is planning care for a postpartum client who expresses a desire to follow the traditional beliefs regarding the balance of yin and yang for postpartum care.
Which of the following actions should the nurse plan to take?