Nokea
A 25-year-old primiparous client who delivered a viable neonate 2 hours ago has decided to breast-feed her neonate. Which of the following instructions should the nurse address as the highest priority in the teaching plan about preventing nipple soreness?
- A. Keeping plastic liners in the brassiere to keep the nipple drier.
- B. Placing as much of the areola as possible into the baby's mouth.
- C. Smoothly pulling the nipple out of the mouth after 10 minutes.
- D. Removing any remaining milk left on the nipple with a soft washcloth.
Correct Answer: B
Rationale: Proper latch with the areola in the baby's mouth prevents nipple soreness by reducing trauma.
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When performing Leopold's maneuvers on a primigravid client, the nurse is palpating the uterus as shown below. Which of the following maneuvers is the nurse performing?
- A. First maneuver.
- B. Second maneuver.
- C. Third maneuver.
- D. Fourth maneuver.
Correct Answer: C
Rationale: The third Leopold's maneuver involves palpating the suprapubic area to determine the presenting part and its engagement, typically performed as described in the context. The first identifies the fundal contents, the second locates the fetal back, and the fourth assesses cephalic prominence.
Four hours after cesarean delivery of a neonate weighing 4,000 g (8 lb, 13 oz), the primiparous client asks, "If I get pregnant again, will I need to have a cesarean?" When responding to the client, the nurse should base the response to the client about vaginal birth after cesarean delivery (VBAC) on which of the following?
- A. VBAC may be possible if the client has not had a classic uterine incision.
- B. A history of rapid labor is a necessary criterion for VBAC.
- C. A low transverse incision contraindicates the possibility for VBAC.
- D. VBAC is not possible because the neonate was large for gestational age.
Correct Answer: A
Rationale: VBAC is often possible with a low transverse incision, unlike a classic vertical incision.
The nurse explains the complications of pregnancy that occur with diabetes to a primigravid client at 10 weeks' gestation who has a 5-year history of insulin-dependent diabetes. Which of the following, if stated by the client as a complication, indicates the need for additional teaching?
- A. Candida albicans infection.
- B. Twin-to-twin transfer.
- C. Polyhydramnios.
- D. Preeclampsia.
Correct Answer: B
Rationale: Twin-to-twin transfer is not a complication of diabetes.
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.
While the nurse is preparing to assist the primiparous client to the bathroom to void 6 hours after a vaginal delivery under epidural anesthesia, the client says that she feels dizzy when sitting up on the side of the bed. The nurse explains that this is most likely caused by which of the following?
- A. Effects of the anesthetic during labor.
- B. Hemorrhage during the delivery process.
- C. Effects of analgesics used during labor.
- D. Decreased blood volume in the vascular system.
Correct Answer: A
Rationale: Dizziness when sitting up is likely due to residual effects of epidural anesthesia, which can cause orthostatic hypotension.