A client who is postpartum and has thrombophlebitis requires nursing interventions. Which of the following nursing interventions should the nurse recommend?

Correct Answer: D

Rationale: The correct answer is D - Measure leg circumferences. This is important in assessing for changes in swelling, which can indicate worsening thrombophlebitis. Monitoring leg circumferences helps in early detection of complications like deep vein thrombosis. Applying cold compresses (A) can worsen vasoconstriction, massage (B) can dislodge clots, and allowing ambulation (C) can increase the risk of clot migration.

Correct Answer: C

Rationale: The correct answer is C. Cleaning the penis with each diaper change is crucial for proper circumcision care to prevent infection. This statement shows understanding of the teaching as it emphasizes the importance of keeping the area clean. A: The circumcision healing within a couple of days is incorrect as it usually takes about 1-2 weeks. B: Not removing the yellow mucus can lead to infection, so this is an incorrect statement. D: Giving a tub bath within a couple of days can increase the risk of infection, so this statement is incorrect.

Correct Answer: C

Rationale: Rationale: - MSAFP screening is recommended for all pregnant clients to assess risk of neural tube defects or chromosomal abnormalities. - It is a standard prenatal test regardless of specific medical conditions. - Options A, B, and D are not directly related to the indication for MSAFP screening in pregnancy.

Correct Answer: D

Rationale: The correct answer is D because providing reinforcement about infant care when the parent is present can help build the parent's confidence and competence in caring for the newborn, which can enhance parent-infant bonding. By offering support and guidance during interactions with the newborn, the parent can feel more comfortable and connected to the baby. A: Handing the parent the newborn and suggesting they change the diaper may increase their anxiety and not address the underlying issue of bonding. B: Asking the parent why they are anxious and nervous is important but may not directly promote bonding without providing concrete support. C: Telling the parent they will grow accustomed to the newborn does not actively support bonding or address the parent's current concerns. In summary, choice D is the best option as it provides practical assistance and positive reinforcement to help the parent feel more confident in caring for the newborn, ultimately fostering parent-infant bonding.

Correct Answer: B

Rationale: The correct answer is B: Weakened uterine contractions. Terbutaline is a tocolytic medication that inhibits uterine contractions. This helps prevent preterm labor. At 28 weeks of gestation, the nurse would expect terbutaline to weaken uterine contractions, rather than increase fetal heart rate (choice A), enhance fetal lung surfactant production (choice C), or lower maternal blood glucose levels (choice D). Weakening of uterine contractions is the expected therapeutic effect of terbutaline in this scenario to delay preterm labor.

Correct Answer: C

Rationale: The correct answer is C: Sunken fontanels. This finding indicates dehydration in the infant, which can be a serious complication requiring immediate intervention. Dehydration can lead to further elevation of bilirubin levels and potential neurological complications. Reporting this to the charge nurse is crucial for prompt assessment and intervention. Incorrect choices: A: Conjunctivitis - Although important, it is not a priority over a sign of dehydration. B: Bronze skin discoloration - This may be a common side effect of phototherapy and does not indicate an urgent issue. D: Maculopapular skin rash - While it should be monitored, it does not take precedence over a sign of dehydration.

Correct Answer: C

Rationale: The correct answer is C: Sore nipple with cracks and fissures. This is indicative of possible breastfeeding issues like improper latch or infection, requiring prompt intervention to prevent complications. Scant, non-odorous white vaginal discharge (A) is normal postpartum lochia. Uterine cramping during breastfeeding (B) is common due to oxytocin release. Decreased response with sexual activity (D) is a common postpartum concern but not an urgent issue at 4 weeks. Addressing sore nipples promptly is crucial for successful breastfeeding and maternal well-being.

Correct Answer: A

Rationale: The correct answer is A because chlamydia is commonly treated with a single dose of azithromycin to ensure complete eradication of the infection. This antibiotic is highly effective against chlamydia. Option B is incorrect because both partners need treatment regardless of symptoms. Option C is incorrect as sexual abstinence for 7 days is recommended post-treatment. Option D is incorrect as retesting should be done after 3 months, not 6 months.

Correct Answer: C

Rationale: The correct answer is C: Completely empty each breast at each feeding or use a pump. This is the correct response because it helps to ensure effective milk removal, which is crucial for treating mastitis. By fully emptying the breast, the nurse can prevent milk stasis and promote healing. A: Limiting the time the infant nurses on each breast may lead to incomplete milk removal, worsening the condition. B: Nursing only on the unaffected breast does not address the issue of milk stasis in the affected breast and may lead to further complications. D: Wearing a tight-fitting bra can exacerbate mastitis by restricting milk flow and increasing discomfort.