The nurse is caring for a client following cardiac valve replacement. Which nursing action is correct when obtaining a Homan's sign to screen for thrombophlebitis?
A) Adduction of the lower extremity
B) Assess the pulse on the dorsal aspect of the foot
C) Dorsiflexion of the foot noting calf pain
D) Rotation of the knee noting pain
C
Feedback:
The correct action to obtain a Homan's sign is to dorsiflex the foot noting calf pain. Heat, redness, and swelling also develops along the length of the vein. The other options are part of a circulation and musculoskeletal assessment but not the action for a Homan's sign.
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Following Centers for Disease Control and Prevention guidelines, which recommendation does the school nurse make to parents of middle-school children?
A) All males and females should begin the three-dose HPV vaccine between 12 and 14 years of age. B) All females should begin the three-dose HPV vaccine between 12 and 14 years of age. C) All males and females should begin the three-dose HPV vaccine between 10 and 12 years of age. D) All males should begin the three-dose HPV vaccine at age 9.
Which of the following may be used to relieve localized discomfort after immunization injections? (Select all that apply.)
1. Warm compresses 2. Acetaminophen 3. Antihistamines 4. Decongestants
With regard to rubella and Rh issues, nurses should be aware that:
a. Breastfeeding mothers cannot be vaccinated with the live attenuated rubella virus. b. Women should be warned that the rubella vaccination is teratogenic and that they must avoid pregnancy for 1 month after vaccination. c. Rh immune globulin is safely administered intravenously because it cannot harm a nursing infant. d. Rh immune globulin boosts the immune system and thereby enhances the effec-tiveness of vaccinations.
The postpartum client states that she doesn't understand why she can't enjoy being with her baby. What would the nurse be concerned about?
1. Postpartum psychosis 2. Postpartum infection 3. Postpartum depression 4. Postpartum blues