A nurse is reinforcing teaching with a client who is at 10 weeks of gestation regarding the purposes of laboratory tests.Which of the following statements by the client indicates an understanding of the teaching?
White blood cell count is an indicator of anemia.
Urine specific gravity identifies my risk for pregnancy-induced hypertension.
Sedimentation rate checks for signs of cancer.
Platelet count identifies if I am at risk for bleeding.
The Correct Answer is D
Choice A rationale
White blood cell count is not an indicator of anemia. It measures immune function and can indicate infection or inflammation.
Choice B rationale
Urine specific gravity does not identify the risk for pregnancy-induced hypertension. It measures the concentration of urine and can indicate hydration status.
Choice C rationale
Sedimentation rate does not check for signs of cancer. It measures inflammation in the body and can indicate various conditions.
Choice D rationale
Platelet count identifies if the client is at risk for bleeding. Low platelet levels can indicate a higher risk of bleeding and are important to monitor during pregnancy.
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Correct Answer is C
Explanation
Choice A rationale
Nursing the baby for 5 to 10 minutes on each breast may not be sufficient for the baby to receive the hindmilk, which is rich in fat and essential for growth.
Choice B rationale
Applying vitamin E oil to the nipples after each feeding is not recommended as it can cause irritation and is not necessary for nipple care.
Choice C rationale
Laying the baby on a pillow at the level of the breast helps ensure proper positioning and latch, which is crucial for effective breastfeeding and preventing nipple soreness.
Choice D rationale
Ensuring that just the nipple is in the baby’s mouth is incorrect. The baby should latch onto the areola, not just the nipple, to ensure effective milk transfer and prevent nipple pain.
Correct Answer is ["D","G","H"]
Explanation
Choice A rationale
Deep tendon reflexes of 1+ are considered within normal limits and do not require immediate follow-up. This finding is not indicative of any acute complications.
Choice B rationale
A blood pressure reading of 136/86 mm Hg is slightly elevated but not critically high. It does not indicate an immediate risk and can be monitored with routine care.
Choice C rationale
A pain rating of 3 on a scale of 0 to 10 is mild and manageable. It does not necessitate immediate follow-up unless there is a sudden and significant increase in pain.
Choice D rationale
A large amount of lochia rubra can be a sign of excessive bleeding and requires immediate follow-up to assess for postpartum hemorrhage. This finding is concerning and needs prompt attention.
Choice E rationale
Peripheral edema of 2+ in bilateral lower extremities is common in the postpartum period due to fluid shifts and should resolve naturally. It does not require immediate follow-up unless it worsens or is accompanied by other symptoms.
Choice F rationale
Soft breasts are normal postpartum when milk has not yet come in or if the client is not breastfeeding. This finding does not require immediate follow-up as it is a normal occurrence.
Choice G rationale
A soft uterine tone can indicate uterine atony, which can lead to hemorrhage. Immediate follow-up is necessary to prevent potential complications such as postpartum hemorrhage.
Choice H rationale
Lateral deviation of the uterus can indicate a displaced uterus, possibly due to a full bladder or other reasons, which requires prompt attention. This finding could lead to complications if not addressed promptly.