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A 16-year-old primigravid client, with a history of attending one prenatal visit, is admitted to the hospital in active labor at 37 weeks' gestation. Her cervix is 7 cm dilated with the presenting part at 0 station. She enters the labor unit appearing anxious and hyperventilating. Because of the hyperventilation, the nurse should assess the client for:
- A. Metabolic alkalosis.
- B. Metabolic acidosis.
- C. Respiratory alkalosis.
- D. Respiratory acidosis.
Correct Answer: C
Rationale: Hyperventilation causes excessive exhalation of carbon dioxide, leading to respiratory alkalosis (elevated blood pH). Metabolic imbalances are less likely, and respiratory acidosis occurs with hypoventilation.
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After instructing a primiparous client who is bottle-feeding about burping, which of the following client statements indicates that the client needs further teaching?
- A. I'll burp him after 15 minutes of feeding him formula.
- B. After he takes one-half ounce of formula, I'll burp him.
- C. I'll burp him while he is in an upright position.
- D. I'll gently pat his back to get him to burp.
Correct Answer: B
Rationale: Burping after one-half ounce is too frequent and may disrupt feeding; burping every 1-2 ounces is more appropriate.
A primiparous client who is bottle-feeding her neonate at 12 hours after birth asks the nurse, "When will my menstrual cycle return?" Which of the following responses by the nurse would be most appropriate?
- A. Your menstrual cycle will return in 3 to 4 weeks.
- B. It will probably be 6 to 10 weeks before it starts again.
- C. You can expect your menses to start in 12 to 14 weeks.
- D. Your menses will return in 16 to 18 weeks.
Correct Answer: B
Rationale: For bottle-feeding mothers, menstruation typically resumes 6 to 10 weeks postpartum due to the absence of breastfeeding's hormonal suppression.
A multiparous client, 28 hours after cesarean delivery, who is breast-feeding complains of severe cramps or afterpains. The nurse explains that these are caused by which of the following?
- A. Flatulence accumulation after a cesarean delivery.
- B. Healing of the abdominal incision after cesarean delivery.
- C. Adverse effects of the medications administered after delivery.
- D. Release of oxytocin during the breast-feeding session.
Correct Answer: D
Rationale: Breastfeeding stimulates oxytocin release, causing uterine contractions (afterpains) as the uterus involutes.
A primiparous client asks the nurse about resuming exercise after vaginal delivery. The nurse should advise the client to start low-impact exercises:
- A. Immediately after discharge.
- B. After 2 weeks postpartum.
- C. After 6 weeks postpartum.
- D. When lochia has completely stopped.
Correct Answer: C
Rationale: Low-impact exercises are generally safe after 6 weeks, allowing time for healing and recovery.
A client is considering permanent contraception. Which of the following statements by the nurse is accurate?
- A. Tubal ligation and vasectomy are considered reversible procedures.
- B. Both tubal ligation and vasectomy require a follow-up to confirm effectiveness.
- C. Tubal ligation affects hormone production.
- D. Vasectomy increases the risk of prostate cancer.
Correct Answer: B
Rationale: Both tubal ligation and vasectomy require follow-up to confirm effectiveness (e.g., sperm count for vasectomy, imaging for tubal ligation). Reversal is not guaranteed, tubal ligation does not affect hormones, and vasectomy is not linked to prostate cancer.