The nurse is teaching an early pregnancy class for clients in the first trimester of pregnancy. Which statement requires immediate intervention by the nurse?
1. "When my nausea is bad, I will drink some ginger tea."
2. "It is normal for my vaginal discharge to get green colored."
3. "I will urinate less often during the middle of my pregnancy."
4. "The fatigue I am experiencing will improve in the second trimester."
2
Explanation:
1. Ginger helps nausea, and is safe for use during pregnancy.
2. Leukorrhea is an increase in white vaginal discharge and is an expected finding during pregnancy. Green discharge is not a normal finding and could indicate an infection. Further assessment is required for a client with green vaginal discharge.
3. As the uterus rises in the pelvis during the second trimester, urinary frequency decreases. Urinary frequency increases again during the end of the third trimester as the fetal head descends into the pelvis.
4. First-trimester fatigue is common; fatigue usually improves during the second trimester.
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a. Applying warm blankets when the patient reports feeling chilly b. Holding the patient's hand to allay anxiety before anesthesia is administered c. Double-checking that the surgical site is clearly marked and visible after draping d. Using calming speech with a reassuring tone of voice when speaking with the patient
Psychotropic medications can cause a parasympathetic and/or sympathetic response from the autonomic nervous system. Which of the following is considered a sympathetic response?
a. Pupil dilation b. Increased saliva production c. Decreased heart rate d. Constricted airway
Designated healthcare surrogates should base healthcare decisions on:
a. personal beliefs and values. b. recommendations of family members and friends. c. recommendations of the physician and healthcare team. d. wishes previously expressed by the patient.
The client with otitis media has purulent material draining from the affected ear. What is the nurse's first action?
A. Irrigate the affected ear. B. Gently examine the affected ear with an otoscope. C. Pack the affected ear and apply a pressure dressing. D. Obtain a specimen of the draining material for culture.