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A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?
- A. Reassess the client in 2 hr.
- B. Administer simethicone.
- C. Assist the client to empty their bladder.
- D. Instruct the client to lie on their right side.
Correct Answer: C
Rationale: The correct answer is C: Assist the client to empty their bladder. After giving birth vaginally, the uterus should be midline and firm. Palpating it above the umbilicus and to the right indicates a full bladder displacing the uterus. Emptying the bladder will allow the uterus to return to its normal position. A: Reassessing in 2 hours is unnecessary as the issue is a full bladder. B: Administering simethicone is for gas relief and not relevant in this situation. D: Instructing the client to lie on their right side does not address the underlying issue of the full bladder.
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A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider?
- A. Swelling of the face.
- B. Varicose veins in the calves.
- C. Nonpitting 1+ ankle edema.
- D. Hyperpigmentation of the cheeks.
Correct Answer: A
Rationale: The correct answer is A: Swelling of the face. Facial swelling in pregnancy could be a sign of preeclampsia, a serious condition characterized by high blood pressure and protein in the urine. This requires immediate medical attention to prevent complications for both the mother and the baby. Varicose veins in the calves (B) are common in pregnancy but do not pose an immediate threat. Nonpitting 1+ ankle edema (C) is a common finding in pregnancy and typically not concerning unless it worsens. Hyperpigmentation of the cheeks (D) is also a common occurrence during pregnancy known as "the mask of pregnancy" and is not a cause for alarm.
A nurse is caring for a client who is in labor and reports increasing rectal pressure. They are experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that their cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?
- A. Passive descent.
- B. Active.
- C. Early.
- D. Descent.
Correct Answer: D
Rationale: The correct answer is D: Descent. At 9 cm dilation, the client is in the second stage of labor, which consists of the descent and birth of the baby. Increasing rectal pressure indicates fetal descent and impending birth. Contractions 2-3 min apart lasting 80-90 seconds are characteristic of the active phase of the second stage of labor. The passive descent phase occurs earlier when the cervix is not fully dilated. The early phase is part of the first stage of labor. Active labor typically begins when the cervix is around 6 cm dilated. Therefore, D is the correct choice as it aligns with the client's symptoms and stage of labor progression.
A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching?
- A. You should take the medication within 72 hours following unprotected sexual intercourse.
- B. You should avoid taking this medication if you are on an oral contraceptive.
- C. If you don't start your period within 5 days of taking this medication, you will need a pregnancy test.
- D. One dose of this medication will prevent you from becoming pregnant for 14 days after taking it.
Correct Answer: A
Rationale: The correct answer is A: You should take the medication within 72 hours following unprotected sexual intercourse. Levonorgestrel is most effective when taken within 72 hours after unprotected sex to prevent pregnancy. This timing is crucial for its efficacy.
Choice B is incorrect because levonorgestrel can be used in combination with oral contraceptives if needed. Choice C is incorrect as the absence of a period does not always indicate pregnancy, and a pregnancy test may not be necessary. Choice D is incorrect because levonorgestrel is effective for a shorter duration, not 14 days.
A nurse is observing a new guardian caring for their crying newborn who is bottle feeding. Which of the following actions by the guardian should the nurse recognize as a positive parenting behavior?
- A. Lays the newborn across their lap and gently sways.
- B. Places the newborn in the crib in a prone position.
- C. Offers the newborn a pacifier dipped in formula.
- D. Prepares a bottle of formula mixed with rice cereal.
Correct Answer: A
Rationale: The correct answer is A because laying the newborn across the lap and gently swaying helps create a soothing and comforting environment for the baby. This position mimics the closeness and security of being held, promoting bonding and emotional connection between the guardian and the newborn. It also aids in digestion and reduces the risk of choking. Placing the newborn in the crib in a prone position (B) is unsafe as it increases the risk of sudden infant death syndrome. Offering a pacifier dipped in formula (C) may introduce unnecessary calories and disrupt feeding patterns. Preparing a bottle with rice cereal (D) can pose a choking hazard and is not recommended for newborns.
A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?
- A. Acrocyanosis.
- B. Transient strabismus.
- C. Jaundice.
- D. Caput succedaneum.
Correct Answer: C
Rationale: The correct answer is C: Jaundice. Jaundice in a newborn within the first 24 hours can indicate pathological conditions like hemolytic disease or liver dysfunction, requiring immediate attention. Acrocyanosis (A) and caput succedaneum (D) are common benign conditions in newborns. Transient strabismus (B) is a temporary eye misalignment that often resolves on its own. Other choices are not provided.