A client who is at 24 weeks of gestation and reports daily mild headaches is being cared for by a nurse. Which of the following instructions should the nurse include in the plan of care?

Correct Answer: B

Rationale: The correct answer is B: Recommend that the client perform conscious relaxation techniques daily. Headaches during pregnancy can be common due to hormonal changes and increased blood volume. The nurse should recommend non-pharmacological interventions like relaxation techniques to manage headaches safely without medication. Conscious relaxation techniques can help reduce stress and tension, potentially alleviating headaches. Ibuprofen (choice A) is not recommended during pregnancy due to potential harm to the fetus. Ginseng tea (choice C) is not safe for pregnant women as it may lead to complications. Soaking in a hot bath (choice D) with a water temperature of 105°F can raise the body temperature, which is not advised during pregnancy as it may harm the baby.

Correct Answer: A

Rationale: Correct Answer: A - Cover the newborn's eyes with an opaque eye mask while under the phototherapy light. Rationale: 1. Phototherapy light can cause eye damage, so covering the newborn's eyes with an opaque eye mask protects them. 2. Newborns' eyes are more sensitive to light, making eye protection crucial during phototherapy. Summary of Incorrect Choices: B: Keeping the newborn in a shirt won't protect the eyes from phototherapy light. C: Applying lotion can interfere with the effectiveness of phototherapy and may cause skin irritation. D: Turning and repositioning the newborn is important for comfort, but eye protection is the priority during phototherapy.

Correct Answer: C

Rationale: The correct answer is C because it accurately describes an episiotomy as an incision made by the provider to facilitate delivery of the fetus. This information is crucial for the client to understand the purpose and potential benefits of the procedure. A: While choice A is similar to the correct answer, it includes unnecessary detail about who makes the incision, which may confuse the client. B: Choice B is incorrect as it provides inaccurate information about a fourth-degree episiotomy extending into the rectal area, which is not recommended as it would involve cutting through the anal sphincter. D: Choice D is incorrect because it introduces unnecessary information about the types of episiotomies without providing the basic understanding of what an episiotomy is.

Correct Answer: D

Rationale: The correct answer is D: Report of severe shoulder pain. In a ruptured ectopic pregnancy, the fertilized egg implants outside the uterus, usually in the fallopian tube. As the tube ruptures, there is internal bleeding which can irritate the diaphragm, causing referred pain to the shoulder. This phenomenon is known as Kehr's sign. The other choices are incorrect because with a ruptured ectopic pregnancy, there would typically be altered menses due to the pregnancy disruption, a transvaginal ultrasound would not show a fetus in the uterus, and blood progesterone levels would not be elevated.

Correct Answer: B

Rationale: Rationale: Massaging the client's fundus helps to stimulate uterine contractions and control postpartum hemorrhage caused by uterine hypotonicity. This action helps prevent further blood loss and promotes uterine tone. Checking capillary refill would not directly address the immediate issue of hemorrhage. Inserting a urinary catheter is not a priority in managing postpartum hemorrhage. Preparing for a blood transfusion may be necessary later, but addressing the uterine hypotonicity and hemorrhage is the priority.

Correct Answer: C

Rationale: The correct answer is C: Shortness of breath. This is because shortness of breath can indicate a potentially serious side effect like a blood clot, which is a rare but serious complication associated with oral contraceptives. Reduced menstrual flow (A) is a common side effect and not typically a cause for concern. Breast tenderness (B) is a common but generally benign side effect of oral contraceptives. Increased appetite (D) is also a common side effect but not typically a sign of a serious complication. Therefore, the healthcare provider should emphasize the importance of reporting shortness of breath promptly.

Correct Answer: D

Rationale: The correct answer is D: Keep a daily record of fetal kick counts. This is important for monitoring fetal well-being, especially in cases of premature rupture of membranes. By counting fetal kicks daily, the client can assess fetal movements and report any changes promptly to healthcare providers. This helps in early detection of fetal distress or problems. A: Using a condom with sexual intercourse is not relevant to the situation of premature rupture of membranes. B: Avoiding bubble bath solution is important for preventing vaginal infections but not directly related to monitoring fetal well-being. C: Wiping from front to back during perineal hygiene is a general hygiene practice and not specific to the situation of premature rupture of membranes.

Correct Answer: C

Rationale: The correct answer is C: You should empty your bladder before the procedure. This is important because a full bladder can obstruct the visualization of the fetus during amniocentesis. By emptying the bladder, the uterus is better positioned for the procedure, making it safer and more effective. Explanation: 1. A (You will lie on your right side during the procedure) is incorrect because the position during amniocentesis is typically on the back or slightly tilted to the left. 2. B (You should not eat anything for 24 hours before the procedure) is incorrect as fasting is not required for amniocentesis. 3. D (The test is performed to determine gestational age) is incorrect as amniocentesis is used to detect genetic abnormalities, not gestational age.

Correct Answer: D

Rationale: The correct answer is D, All of the Above. 1. Decreased fetal movement indicates fetal distress, necessitating CST. 2. IUGR implies potential placental insufficiency, requiring CST evaluation. 3. Postmaturity increases risk of placental insufficiency, warranting CST. Other choices are incorrect as they do not directly indicate the need for CST in a pregnant client.