Nokea
A nurse is teaching a client and her partner about the technique of counterpressure during labor. Which of the following statements by the nurse is appropriate?
- A. Your partner will apply pressure to the top of your uterus during contractions.
- B. Your partner will apply steady pressure with a tennis ball to your lower back.
- C. Your partner will apply continuous, firm pressure between your thumb and index finger.
- D. Your partner will apply upward pressure on your lower abdomen between contractions.
Correct Answer: B
Rationale: Counterpressure on the lower back with a tennis ball relieves labor pain, unlike uterine pressure (harmful), hand pressure (ineffective), or abdominal pressure (unrelated to pain relief).
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A nurse is providing teaching to a client who is primigravid and is scheduled to have an abdominal ultrasound. Which of the following statements by the client indicates an understanding of the teaching?
- A. I won't apply perfumed lotion to my abdomen before the test.
- B. I can't have anything to eat after midnight.
- C. I need to take a stool softener the night before the test.
- D. I will drink water before the test until my bladder feels full.
Correct Answer: D
Rationale: A full bladder enhances ultrasound visibility by displacing intestines, unlike avoiding lotion, fasting, or stool softeners, which are not required.
A nurse is reviewing the electronic medical record of a postpartum client. The nurse should identify that which of the following factors places the client at risk for an infection?
- A. Midline episiotomy
- B. Meconium-stained fluid
- C. Gestational hypertension
- D. Placenta previa
Correct Answer: B
Rationale: Meconium-stained fluid increases maternal infection risk if it enters the bloodstream, unlike episiotomy (managed risk), hypertension, or previa (other complications).
A nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery and reports constipation. Which of the following findings should the nurse identify as a contraindication to the use of a suppository?
- A. Abdominal distention
- B. Third-degree perineal laceration
- C. Vaginal candidiasis
- D. Afterpain
Correct Answer: B
Rationale: A third-degree perineal laceration contraindicates suppositories to avoid further trauma and delayed healing, unlike distention, candidiasis, or afterpain, which are not contraindications.
A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions should the nurse include in the plan of care?
- A. Instruct the client to stop taking the antiretroviral medications at 32 weeks of gestation.
- B. Use a fetal scalp electrode during labor and delivery.
- C. Bathe the newborn before initiating skin-to-skin contact.
- D. Administer a pneumococcal immunization to the newborn within 4 hr following birth.
Correct Answer: C
Rationale: Bathing the newborn removes maternal fluids, reducing HIV transmission risk, unlike stopping antiretrovirals (continued), scalp electrodes (increase risk), or pneumococcal vaccine (not routine).
A nurse is caring for a client who is postpartum and experiencing hypovolemic shock. Which of the following findings should the nurse expect?
- A. Cool, Clammy skin
- B. Respiratory rate 18/min
- C. Bounding pulses
- D. Urinary output 30 mL/hr
Correct Answer: A
Rationale: Cool, clammy skin results from vasoconstriction in hypovolemic shock, unlike normal respiratory rate, bounding pulses (compensatory tachycardia typical), or low-normal urine output.