Nokea
A laboring client smiles pleasantly at the nurse when asked simple questions. The client speaks no English and the interpreter is busy with an emergency situation. At her last vaginal examination, the client was 5 cm dilated, 100% effaced, and at 0 station. While working with this client, which of the following responses indicates that the client may be approaching delivery?
- A. The fetal monitor strip shows late decelerations.
- B. The client begins to speak to her family in her native language.
- C. The fetal monitor strip shows early decelerations.
- D. The client's facial expressions become animated.
Correct Answer: D
Rationale: Animated facial expressions (e.g., grimacing, distress) may indicate transition or second-stage labor, suggesting imminent delivery. Late decelerations indicate fetal distress, speaking to family is nonspecific, and early decelerations are normal.
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A client delivered 2 days ago and has been given instructions on breast care for bottle-feeding mothers. Which of the following statements indicates that the nurse should reinforce the instructions to the client?
- A. I will wear a sports bra or a well fitting bra for several days.
- B. When showering, I'll direct water onto my shoulders.
- C. I will only use only water to clean my nipples.
- D. I will use a breast pump to remove any milk that may appear.
Correct Answer: D
Rationale: Using a breast pump can stimulate milk production, which is counterproductive for bottle-feeding mothers.
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.
The nurse is teaching a group of women about fertility awareness methods of contraception. Which of the following would the nurse include as the most reliable indicator that ovulation has occurred?
- A. A slight drop followed by a rise in basal body temperature.
- B. A change in cervical mucus to thin, clear, and stretchy.
- C. The onset of mittelschmerz, or midcycle pelvic pain.
- D. The presence of a thick, cloudy cervical mucus.
Correct Answer: A
Rationale: A slight drop followed by a rise in basal body temperature is the most reliable indicator of ovulation, as it reflects the hormonal shift post-ovulation. Cervical mucus changes and mittelschmerz are less precise, and thick mucus typically occurs post-ovulation.
After the nurse counsels a primiparous client who is breast-feeding her neonate about diet and nutritional needs during the lactation period, which of the following client statements indicates a need for additional teaching?
- A. I need to increase my intake of vitamin D.
- B. I should drink at least five glasses of fluid daily.
- C. I need to get an extra 500 calories per day.
- D. I need to make sure I have enough calcium in my diet.
Correct Answer: B
Rationale: Breastfeeding mothers need 8-10 glasses of fluid daily to support milk production, so five glasses is insufficient.
The nurse discovers a medication error where a postpartum client received 400 mg of ibuprofen instead of 800 mg. The nurse should:
- A. Monitor the client for adverse effects.
- B. Administer the remaining 400 mg immediately.
- C. Notify the physician and complete an incident report.
- D. Document the dose as administered without reporting.
Correct Answer: C
Rationale: Notifying the physician and filing an incident report ensures patient safety and proper follow-up.