Nokea
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 primiparous client, who has just delivered a healthy term neonate after 12 hours of labor, holds and looks at her neonate and begins to cry. The nurse interprets this behavior as a sign of which of the following?
- A. Disappointment in the baby's gender.
- B. Grief over the ending of the pregnancy.
- C. A normal response to the birth.
- D. Indication of postpartum 'blues.'
Correct Answer: C
Rationale: Crying after delivery is a normal emotional response to the intense experience of birth, reflecting joy, relief, or overwhelming emotions. It does not indicate disappointment, grief, or postpartum blues, which typically manifest later.
While the nurse is caring for a primiparous client with cephalopelvic disproportion 4 hours after a cesarean delivery, the client requests assistance in breast-feeding. To promote maximum maternal comfort, which of the following would be most appropriate for the nurse to suggest?
- A. Football hold.
- B. Scissors hold.
- C. Cross-cradle hold.
- D. Cradle hold.
Correct Answer: A
Rationale: The football hold minimizes pressure on the cesarean incision, promoting comfort during breastfeeding.
A nurse is discussing sterilization options with a male client. Which of the following statements by the client indicates a need for further teaching?
- A. A vasectomy involves cutting the vas deferens to prevent sperm release.
- B. I will need to use another contraceptive method until my sperm count is zero.
- C. A vasectomy will decrease my testosterone levels.
- D. A vasectomy is considered a permanent form of contraception.
Correct Answer: C
Rationale: A vasectomy does not decrease testosterone levels, as the testes continue to produce hormones. The other statements are correct, indicating a need for further teaching about hormonal effects.
On arrival at the emergency department, a client tells the nurse that she suspects that she may be pregnant but has been having a small amount of bleeding and has severe pain in the lower abdomen. The client's blood pressure is 70/50 mm Hg and her pulse rate is 120 bpm. The nurse notifies the physician immediately because of the possibility of:
- A. Ectopic pregnancy.
- B. Abruptio placentae.
- C. Gestational trophoblastic disease.
- D. Complete abortion.
Correct Answer: A
Rationale: Severe pain and hypotension suggest ectopic pregnancy.
A female neonate delivered vaginally at term with a cleft lip and cleft palate is admitted to the regular nursery. Which of the following actions should the nurse do the first time that the parents visit the neonate in the nursery?
- A. Explain the surgical interventions that will be performed.
- B. Stress that this defect is not life-threatening.
- C. Emphasize the neonate's normal characteristics.
- D. Reassure the parents about the success rate of the surgery.
Correct Answer: C
Rationale: Emphasizing the neonate's normal characteristics helps promote bonding and reduces parental anxiety during the initial visit.