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A 39-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor has been diagnosed with class II heart disease. To ensure cardiac emptying and adequate oxygenation during labor, the nurse plans to encourage the client to do which of the following?
- A. Breathe slowly after each contraction.
- B. Avoid the use of analgesics for the labor pain.
- C. Remain in a side-lying position with the head elevated.
- D. Request local anesthesia for vaginal delivery.
Correct Answer: C
Rationale: For class II heart disease, a side-lying position with head elevation reduces cardiac strain by optimizing venous return and oxygenation. Slow breathing is helpful but less specific, avoiding analgesics may increase stress, and local anesthesia is unrelated to cardiac emptying.
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A client asks about the benefits of male condoms. Which of the following would the nurse include?
- A. They are 100% effective in preventing pregnancy.
- B. They provide some protection against STIs.
- C. They can be reused if undamaged.
- D. They require a prescription.
Correct Answer: B
Rationale: Male condoms provide some protection against STIs, which is a key benefit. They are not 100% effective, cannot be reused, and do not require a prescription.
The nurse is making clinical rounds on a group of clients in a newborn nursery. Which infant is at greatest risk of developing respiratory distress syndrome (RDS)?
- A. A neonate born at 36 weeks' gestation.
- B. A neonate born by Cesarean section.
- C. A neonate experiencing apneic episodes.
- D. A neonate who is 42 weeks' gestation.
Correct Answer: C
Rationale: A neonate experiencing apneic episodes is at greatest risk for RDS due to compromised respiratory function.
A postpartum client delivered 6 hours ago without anesthesia and just voided 100 mL. The nurse palpates the fundus 2 fingerbreadths above the umbilicus and off to the right side. What should the nurse do next?
- A. Administer ibuprofen (Motrin).
- B. Reassess in 1 hour.
- C. Catheterize the client.
- D. Administer an I.V. bolus of 500 mL to rehydrate per policy.
Correct Answer: C
Rationale: A deviated fundus and small void suggest bladder distention, requiring catheterization to empty the bladder.
A primigravid client delivered vaginally 2 hours ago with no complications. As the nurse plans care for this postpartum client, which postpartum goal would have the highest priority?
- A. By discharge, the family will bond with the neonate.
- B. The client will demonstrate self-care and infant care by the end of the shift.
- C. The client will state instructions for discharge during the first postpartum day.
- D. By the end of the shift, the client will describe a safe home environment.
Correct Answer: B
Rationale: The highest priority in the immediate postpartum period is ensuring the client can perform self-care and infant care, as this promotes safety and independence, which are critical for recovery and newborn care.
A primiparous client with a neonate who is 36 hours old asks the nurse, "Why does my baby spit up a small amount of formula after feeding?" The nurse explains that the regurgitation is thought to result from which of the following?
- A. An immature cardiac sphincter.
- B. A defect in the gastrointestinal system.
- C. Burping the infant too frequently.
- D. Moving the infant during the feeding.
Correct Answer: A
Rationale: An immature cardiac sphincter in newborns can cause regurgitation of formula.