Nokea
A client with gestational diabetes who is entering her third trimester is learning how to monitor her fetus's movements. After teaching the client about the kick count, the nurse should provide further instruction if the client makes which of the following statements?
- A. "The baby may be more active at different times of the day."
- B. "How I feel my baby move is different than my friend."
- C. "The baby should be moving less than 10 times in 3 hours."
- D. "The baby may not move at times because it is asleep."
Correct Answer: C
Rationale: The baby should move at least 10 times in 2 hours.
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A primigravid client at 41 weeks' gestation is admitted to the hospital's labor and delivery unit in active labor. After 25 hours of labor with membranes ruptured for 24 hours, the client delivers a healthy neonate vaginally with a midline episiotomy. Which of the following nursing diagnoses should the nurse identify as the priority for the client?
- A. Activity intolerance related to difficult labor process.
- B. Sleep deprivation related to prolonged labor.
- C. Situational low self-esteem related to lengthy labor process.
- D. Risk for infection related to birth trauma and prolonged ruptured membranes.
Correct Answer: D
Rationale: Prolonged rupture of membranes (>24 hours) and episiotomy increase infection risk, making this the priority post-delivery. Activity intolerance, sleep deprivation, and self-esteem are less urgent.
The nurse is caring for a multigravid client who speaks little English. As the nurse enters the client's room, the nurse observes the client panting on the bed and the fetal head crowning. After calling for assistance and helping the client lie down, which of the following actions should the nurse do next?
- A. Tell the client to push between contractions.
- B. Provide gentle support to the fetal head.
- C. Apply gentle upward traction on the neonate's anterior shoulder.
- D. Massage the perineum to stretch the perineal tissues.
Correct Answer: B
Rationale: With the fetal head crowning, providing gentle support prevents rapid expulsion and perineal trauma. Pushing between contractions is incorrect, traction is for shoulder dystocia, and perineal massage is less urgent.
A newly delivered client is asking to go to the bathroom 45 minutes after delivery. She had an epidural for labor & delivery, has an IV infusing, and every 15 minutes assessments are in progress. To provide the safest care for this client the nurse should:
- A. Ask her to remain in bed until the 15-minute assessments are complete.
- B. Assess client's ability to stand and bear weight before going to the bathroom.
- C. Encourage the client to sit at the side of the bed before ambulating to the bathroom.
- D. Ask the client to ambulate the first time with a staff member at her side.
Correct Answer: B
Rationale: Post-epidural, assessing the client's ability to stand and bear weight ensures safety due to potential residual numbness or weakness. Remaining in bed delays care, sitting first is insufficient, and ambulating with assistance assumes mobility not yet confirmed.
A nurse is discussing the contraceptive implant with a client. Which of the following client statements indicates understanding?
- A. The implant is effective for up to 3 years.
- B. The implant requires daily monitoring.
- C. The implant protects against STIs.
- D. The implant is taken orally.
Correct Answer: A
Rationale: The contraceptive implant is effective for up to 3 years, providing long-term contraception. It does not require daily monitoring, protect against STIs, or involve oral administration.
An antenatal G 2, T 1, P 0, Ab 0, L 1 client is discussing her postpartum plans for birth control with the health care provider. In analyzing the available choices, which of the following factors has the greatest impact on her birth control options?
- A. Satisfaction with prior methods.
- B. Preference of sexual partner.
- C. Breast- or bottle-feeding plan.
- D. History of clotting disease.
Correct Answer: D
Rationale: A history of clotting disease significantly impacts birth control options, as hormonal methods like combined oral contraceptives may increase the risk of thromboembolism, making non-hormonal or progestin-only methods safer choices.