Nokea
A client in active labor reports back pain while being examined by a nurse who finds her to be 8 cm dilated, 100% effaced, -2 station, and in the occiput posterior position. What action should the nurse take?
- A. Perform effleurage during contractions.
- B. Place the client in lithotomy position.
- C. Assist the client to the hands and knees position.
- D. Apply a scalp electrode to the fetus.
Correct Answer: C
Rationale: The correct action is to assist the client to the hands and knees position. This position, also known as the all-fours position, can help alleviate back pain by encouraging the baby to rotate into a more favorable position for delivery. By being on hands and knees, gravity assists in the rotation of the baby. This position can also help relieve pressure on the mother's back and potentially facilitate a smoother labor progress. Effleurage (choice A) may provide comfort but doesn't address the positional issue. Placing the client in lithotomy position (choice B) can worsen the occiput posterior position. Applying a scalp electrode to the fetus (choice D) is not indicated in this scenario.
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A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following interventions should the nurse include in the plan?
- A. Monitor the client's blood pressure every hour.
- B. Restrict the total hourly intake to 200 mL.
- C. Monitor the FHR continuously.
- D. Administer protamine sulfate for manifestations of toxicity.
Correct Answer: C
Rationale: The correct answer is C: Monitor the FHR continuously. This is essential in preeclampsia as magnesium sulfate can affect fetal heart rate (FHR). Continuous monitoring helps detect any changes promptly.
A: Monitoring blood pressure is important but not as critical as FHR monitoring in this scenario.
B: Restricting total hourly intake to 200 mL is not necessary for magnesium sulfate administration.
D: Administering protamine sulfate is incorrect as it is used for heparin toxicity, not magnesium sulfate toxicity.
A client who is postpartum is receiving discharge teaching from a nurse. For which of the following clinical manifestations should the client be instructed to monitor and report to the provider?
- A. Persistent abdominal striae
- B. Temperature 37.8° C (100.2° F)
- C. Unilateral breast pain
- D. Brownish-red discharge on day 5
Correct Answer: C
Rationale: Rationale: Unilateral breast pain in a postpartum client can indicate mastitis, a bacterial infection of the breast tissue. This requires prompt medical attention to prevent complications like abscess formation.
Other Choices:
A: Abdominal striae are normal after pregnancy and don't require immediate intervention.
B: Mild temperature elevation is common postpartum and doesn't necessarily indicate infection.
D: Brownish-red discharge on day 5 is typically normal lochia and not concerning unless foul-smelling or accompanied by fever.
When reviewing postpartum nutrition needs with breastfeeding clients, which statement indicates an understanding of the teaching?
- A. I am glad I can have my morning coffee.
- B. I should take folic acid to increase my milk supply.
- C. I will continue adding 330 calories per day to my diet.
- D. I will continue my calcium supplements because I don't like milk.
Correct Answer: D
Rationale: The correct answer is D because it demonstrates an understanding of the importance of calcium intake for breastfeeding mothers. Calcium is essential for both the mother's health and the baby's bone development. Continuing calcium supplements shows a commitment to meeting nutritional needs.
Incorrect choices:
A: Having coffee is fine, but it's not directly related to postpartum nutrition needs.
B: Folic acid is important for pregnancy but not specifically for increasing milk supply.
C: While additional calories are needed during breastfeeding, the specific amount varies and is not always 330 calories per day.
A client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?
- A. Check the client's temperature.
- B. Observe for uterine contractions.
- C. Administer Rho(D) immune globulin.
- D. Monitor the fetal heart rate (FHR).
Correct Answer: D
Rationale: The correct answer is D: Monitor the fetal heart rate (FHR). After an amniocentesis, the priority is monitoring FHR to assess fetal well-being and detect any signs of distress. This is crucial as the procedure carries a risk of causing fetal distress. Checking the client's temperature (A) is important but not the priority. Observing for uterine contractions (B) is important but not immediate post-amniocentesis. Administering Rho(D) immune globulin (C) is typically done in cases of Rh incompatibility and not directly related to the amniocentesis procedure.
A client in a prenatal clinic is receiving education from a nurse and mentions, 'I don't like milk.' Which of the following foods should the nurse recommend as a good source of calcium?
- A. Dark green leafy vegetables
- B. Deep red or orange vegetables
- C. White bread and rice
- D. Meat, poultry, and fish
Correct Answer: A
Rationale: The correct answer is A: Dark green leafy vegetables. Dark green leafy vegetables like kale, spinach, and broccoli are excellent sources of calcium. They provide a good alternative to dairy for those who don't like milk. These vegetables are rich in calcium, which is essential for bone health, especially during pregnancy. They also offer other nutrients like vitamin K and magnesium that support calcium absorption.
Summary:
B: Deep red or orange vegetables - While these vegetables are nutritious, they are not significant sources of calcium.
C: White bread and rice - These foods do not provide a significant amount of calcium.
D: Meat, poultry, and fish - While these foods are rich in protein and other nutrients, they are not primary sources of calcium.