Nokea
A 24-year-old primigravid client who delivers a viable term neonate is ordered to receive the primary effect of the placenta. Which of the following signs would indicate to the nurse that the placenta is about to be delivered?
- A. The cord lengthens outside the vagina.
- B. There is decreased vaginal bleeding.
- C. The uterus cannot be palpated.
- D. Uterus changes to discoid shape.
Correct Answer: A
Rationale: A lengthening umbilical cord outside the vagina indicates placental separation and descent, signaling imminent delivery. Decreased bleeding or a non-palpable uterus are not reliable signs, and the uterus becomes globular, not discoid, after placental delivery.
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A primiparous client, 48 hours after a vaginal delivery, is to be discharged with a prescription for vitamins with iron because she is anemic. To maximize absorption of the iron, the nurse instructs the client to take the medication with which of the following?
- A. Orange juice.
- B. Herbal tea.
- C. Milk.
- D. Grape juice.
Correct Answer: A
Rationale: Vitamin C in orange juice enhances iron absorption, unlike milk, which can inhibit it.
While the nurse is caring for a multiparous client in active labor at 36 weeks' gestation, the client tells the nurse, 'I think my water just broke.' Which of the following should the nurse do first?
- A. Turn the client to the right side.
- B. Assess the color, amount, and odor of the fluid.
- C. Assess the fetal heart rate pattern.
- D. Check the client's cervical dilation.
Correct Answer: C
Rationale: Rupture of membranes can affect fetal well-being, particularly in preterm labor (36 weeks). Assessing the fetal heart rate pattern first ensures the fetus is not in distress (e.g., due to cord compression). Fluid characteristics and dilation are assessed next.
While caring for a moderately obese primigravid client in active labor at term, the nurse should monitor the client for signs of which of the following?
- A. Hypotonic reflexes.
- B. Increased uterine resting tone.
- C. Soft tissue dystocia.
- D. Increased fear and anxiety.
Correct Answer: C
Rationale: Obesity in labor increases the risk of soft tissue dystocia due to excess pelvic fat impeding fetal descent. Hypotonic reflexes are not typically associated with obesity, increased uterine resting tone is more related to hyperstimulation, and while anxiety may occur, it is not specific to obesity-related complications.
A neonate delivered at 37 weeks' gestation has been admitted to the neonatal intensive care unit for respiratory distress. The physician has ordered an I.V. for fluid support. To increase safety prior to hanging new I.V. fluids for a neonate, the nurse should:
- A. Check the neonate's weight.
- B. Determine if the neonate has adequate urine output.
- C. Determine the neonate's glucose level.
- D. Double-check the fluids and physician's order with another nurse.
Correct Answer: D
Rationale: Double-checking the fluids and physician's order with another nurse ensures accuracy and safety, reducing the risk of medication or fluid errors.
Assessment of a 23-year-old primigravid client at term who is admitted to the birthing unit in active labor reveals that her cervix is 4 cm dilated and 100% effaced. Contractions are occurring every 4 minutes. The nurse is developing a care plan with the client to relieve pain based on the gate-control theory of pain. The nurse should explain which of the following to the client?
- A. Input from the large sensory fibers opens the gate.
- B. Labor pain is a matter of individual perception.
- C. Slow abdominal breathing can open the gate.
- D. The gating mechanism is in the spinal cord.
Correct Answer: D
Rationale: The gate-control theory posits that pain signals are modulated in the spinal cord, where non-painful stimuli (e.g., touch) can 'close the gate' to pain transmission. Input from large fibers closes the gate, perception varies but is not the mechanism, and slow breathing helps manage pain but does not open the gate.