A nurse is speaking on the phone to a client on the phone who is pregnant and taking iron supplements for iron-deficiency anemia. The client reports that her stools are black but she has no abdominal pain or cramping. Which of the following responses by the nurse is appropriate?
"Go to the emergency room and your provider will meet you the
"Come to the office and we will check things out."
"What else have you been eating?"
"This is expected because of the way iron is broken down during digestion."
The Correct Answer is D
Choice A rationale:
Going to the emergency room for black stools without abdominal pain or cramping is not warranted in this situation.
Choice B rationale:
Having the client come to the office to check things out may not be necessary since black stools can be an expected side effect of iron supplements and do not necessarily indicate a problem.
Choice C rationale:
Asking about the client's diet is a valid question, but the black stools are likely due to iron supplements' effects and not related to dietary choices.
Choice D rationale:
Black stools are a known side effect of iron supplements. When iron is broken down during digestion, it can cause the stools to appear black or dark. As the client has no other concerning symptoms like abdominal pain or cramping, this response by the nurse reassures the client that the finding is expected and not a cause for alarm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: While colostrum is present in the first few days after delivery, it takes a few more days for breast milk to "come in" and increase in volume.
Choice B rationale: Waiting for 6 to 8 days for breast milk to come in would be too long after childbirth. Breast milk typically "comes in" sooner, around 3 to 5 days after delivery.
Choice C rationale: Colostrum, the first milk, is typically produced in small amounts during the first few days after delivery. Breast milk usually "comes in" or increases in volume around 3 to 5 days after childbirth. This transition from colostrum to mature milk is normal and expected.
Choice D rationale: Waiting for 10 days for breast milk to come in would be too long after childbirth. Breast milk typically "comes in" sooner, around 3 to 5 days after delivery.
Correct Answer is B
Explanation
Choice A rationale: A positive contraction stress test warrants immediate attention and evaluation. Waiting for 24 hours to repeat the test could delay necessary interventions in case of fetal distress.
Choice B rationale: A positive contraction stress test indicates that there are late decelerations in the baby's heart rate during contractions, which may suggest fetal distress. In such cases, it is essential to admit the client to the hospital for further evaluation, monitoring, and appropriate management.
Choice C rationale: Checking the client's cervix for dilation is not the most appropriate action in response to a positive contraction stress test. Fetal well-being and assessment take priority in this situation.
Choice D rationale: A positive contraction stress test requires further action and should not be considered a routine finding. Proper management and evaluation are necessary when the test results are positive.
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