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: D

Rationale: The correct answer is D: Assist the client to the bathroom to void. A boggy and displaced fundus to the right in a postpartum client suggests a full bladder, which can displace the uterus. Voiding helps the uterus contract back to its normal position, reducing the risk of postpartum hemorrhage. Encouraging Kegel exercises (A) is not appropriate in this situation. Moving to the left lateral position (B) may provide temporary relief but does not address the underlying issue. Asking the client to rate her pain (C) is not relevant to the management of a displaced fundus.

Correct Answer: C

Rationale: The Apgar score assesses the newborn's overall condition at birth based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. A score of 6 at 1 minute indicates moderate difficulty in transitioning to extrauterine life. For a score of 6, the baby may have a heart rate below 100 bpm, weak respiratory effort, some muscle tone, grimacing reflex irritability, and a body with bluish extremities but normal body color. Choice C aligns with these criteria. Choices A, B, and D do not meet the requirements for a score of 6 as they represent either too low or too high values in one or more criteria, resulting in a different Apgar score.

Correct Answer: B

Rationale: The correct answer is B: Ask the client if they have thoughts of harming themselves or their infant. This is the priority because postpartum psychosis poses a risk of harm to the client and the infant. Assessing for suicidal or homicidal ideation is crucial to ensure safety. Choice A may be important but ensuring immediate safety takes precedence. Choice C is important but not the priority. Choice D may provide background information but does not address the immediate safety concern.

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: A

Rationale: The correct answer is A: Gradual lordosis. During the third trimester, the growing uterus shifts the center of gravity forward, leading to an increased lumbar curvature known as lordosis. This change helps maintain balance and support the extra weight. Increased abdominal muscle tone (B) is not an expected finding as abdominal muscles tend to stretch and weaken during pregnancy. Posterior neck flexion (C) is not a common physiologic change during the third trimester. Decreased mobility of pelvic joints (D) is incorrect as hormonal changes during pregnancy actually increase flexibility in the pelvic joints to prepare for childbirth.

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: B

Rationale: The correct answer is B: Missed miscarriage. At 11 weeks gestation, the fetus has died but has not been expelled from the uterus. This is known as a missed miscarriage. The other choices are incorrect because: A: Incomplete miscarriage involves partial expulsion of the products of conception. C: Inevitable miscarriage indicates that the miscarriage is in progress and cannot be stopped. D: Complete miscarriage refers to the complete expulsion of all products of conception from the uterus.

Correct Answer: B

Rationale: The correct answer is B: 48/min. The normal respiratory rate for a newborn is typically between 30-60 breaths per minute. It is important to assess a newborn's respiratory rate to ensure proper oxygenation. Option A (22/min) is too low, while options C (100/min) and D (110/min) are too high and could indicate respiratory distress or other issues that need immediate attention. Therefore, option B falls within the expected reference range and is the correct answer for a healthy newborn assessment.