A nurse is reinforcing teaching with a client who is pregnant and reports frequent heartburn.Which of the following recommendations should the nurse include in the teaching?
Lie in a left side-lying position for 30 minutes after meals.
Take sips of milk between meals.
Eat three large meals per day.
Drink a cup of black coffee before breakfast.
The Correct Answer is B
Choice A rationale
Lying in a left side-lying position for 30 minutes after meals can help reduce heartburn symptoms by preventing stomach acid from flowing back into the esophagus. However, it is not the most effective recommendation for managing heartburn during pregnancy.
Choice B rationale
Taking sips of milk between meals can help neutralize stomach acid and provide relief from heartburn. Milk can act as a buffer, reducing the acidity in the stomach and alleviating discomfort.
Choice C rationale
Eating three large meals per day can exacerbate heartburn symptoms by increasing the amount of stomach acid produced. Smaller, more frequent meals are recommended to help manage heartburn during pregnancy.
Choice D rationale
Drinking a cup of black coffee before breakfast can worsen heartburn symptoms due to its acidic nature and caffeine content. It is not recommended for individuals experiencing frequent heartburn, especially during pregnancy.
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Correct Answer is ["F","G","H"]
Explanation
Choice A rationale:
Deep tendon reflexes of 1+ are considered normal and do not indicate any immediate concern. Reflexes are graded on a scale from 0 to 4+, with 2+ being normal. A 1+ reflex is slightly diminished but can be normal in some individuals.
Choice B rationale:
A pain rating of 3 on a scale of 0 to 10 is relatively low and manageable. Postpartum pain is expected, and a rating of 3 does not indicate severe pain that requires immediate intervention.
Choice C rationale:
The blood pressure reading of 136/86 mm Hg is slightly elevated but not alarming. Postpartum blood pressure can fluctuate, and this reading does not indicate a hypertensive crisis.
Choice D rationale:
Peripheral edema of 2+ in the bilateral lower extremities is common postpartum due to fluid retention and is not typically a cause for immediate concern unless accompanied by other symptoms such as severe pain or redness.
Choice E rationale:
Soft breasts with intact nipples are normal findings in the early postpartum period, especially if the client is breastfeeding. There is no indication of issues such as mastitis or engorgement.
Choice F rationale:
A large amount of lochia rubra is concerning as it may indicate postpartum hemorrhage. Lochia should gradually decrease in amount and change in color over time. A large amount of bright red blood suggests excessive bleeding that requires immediate follow-up.
Choice G rationale:
A soft uterine tone is abnormal and can indicate uterine atony, which is a leading cause of postpartum hemorrhage. The uterus should be firm and contracted to prevent excessive bleeding.
Choice H rationale:
Lateral deviation of the uterus can indicate a full bladder, which can prevent the uterus from contracting properly and lead to increased bleeding. This requires immediate attention to ensure the bladder is emptied and the uterus can contract effectively.
Correct Answer is A
Explanation
Choice A rationale
A hemoglobin level of 9.5 g/dL is low for a full-term newborn and should be reported to the provider. Normal hemoglobin levels for newborns range from 14 to 24 g/dL4.
Choice B rationale
A white blood cell count of 10,000/mm³ is within the normal range for a newborn, which is typically between 9,000 and 30,000/mm³4.
Choice C rationale
A glucose level of 60 mg/dL is within the normal range for a newborn, which is typically between 40 and 60 mg/dL4.
Choice D rationale
A platelet count of 225,000/mm³ is within the normal range for a newborn, which is typically between 150,000 and 450,000/mm³4.