Nokea
A 19-year-old primigravid client at 38 weeks' gestation is admitted to the hospital in active labor that began 8 hours ago. When the client's cervix is 7 cm dilated and the presenting part is at +1 station, the client tells the nurse, 'I need to push!' Which of the following would the nurse do next?
- A. Use the McDonald procedure to widen the pelvic opening.
- B. Increase the rate of oxygen and intravenous fluids.
- C. Tell the client to use a pant-blow pattern of breathing.
- D. Tell the client to push only when absolutely necessary.
Correct Answer: C
Rationale: At 7 cm dilation, the client is not fully dilated, and pushing can cause cervical trauma. A pant-blow breathing pattern helps manage the urge to push until full dilation. The McDonald procedure is for cervical cerclage, and increasing oxygen/fluids or encouraging pushing is inappropriate.
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During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she has been experiencing breast engorgement. To relieve engorgement, the nurse teaches the client that before nursing her baby, the client should do which of the following?
- A. Apply an ice cube to the nipples.
- B. Rub her nipples gently with lanolin cream.
- C. Express a small amount of breast milk.
- D. Offer the neonate a small amount of formula.
Correct Answer: C
Rationale: Expressing a small amount of milk softens the breast, making it easier for the neonate to latch.
A nurse is counseling a client about the use of spermicides. Which of the following instructions should the nurse include?
- A. Apply spermicide 10-30 minutes before intercourse.
- B. Use spermicide alone for maximum effectiveness.
- C. Leave spermicide in place for at least 24 hours.
- D. Apply spermicide after intercourse.
Correct Answer: A
Rationale: Spermicide should be applied 10-30 minutes before intercourse for optimal effectiveness. It is not most effective alone, should not be left for 24 hours, and is applied before, not after, intercourse.
A client is considering the contraceptive implant. Which of the following side effects should the nurse discuss?
- A. Guaranteed weight loss.
- B. Irregular bleeding and headaches.
- C. Permanent infertility.
- D. Increased risk of ovarian cancer.
Correct Answer: B
Rationale: The contraceptive implant may cause irregular bleeding and headaches, especially initially. It does not guarantee weight loss, cause permanent infertility, or increase ovarian cancer risk.
A multigravid client in active labor at term is diagnosed with polyhydramnios. The physician has instructed the client about possible neonatal complications related to the polyhydramnios. The nurse determines that the client has understood the instructions when the client states that polyhydramnios is associated with which of the following in the fetus or neonate?
- A. Renal dysfunction.
- B. Intrauterine growth retardation.
- C. Pulmonary hypoplasia.
- D. Gastrointestinal disorders.
Correct Answer: D
Rationale: Polyhydramnios is associated with fetal gastrointestinal disorders (e.g., esophageal atresia) that impair amniotic fluid absorption. Renal dysfunction, growth retardation, or pulmonary hypoplasia are more linked to oligohydramnios.
A neonate at 37 weeks' gestation is delivered by cesarean delivery because of placenta previa. Which of the following would the circulating nurse do first as soon as the neonate is delivered?
- A. Stimulate the neonate to cry vigorously.
- B. Aspirate mucus from the mouth with a bulb syringe.
- C. Begin resuscitation procedures with a bag and mask.
- D. Hold the neonate upright for the mother to view.
Correct Answer: B
Rationale: Aspirating mucus from the mouth with a bulb syringe clears the airway, which is the first priority to ensure breathing.