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A nurse is counseling a client about the use of spermicides. Which of the following instructions should the nurse include?
- A. Apply spermicide 10-30 minutes before intercourse.
- B. Use spermicide alone for maximum effectiveness.
- C. Leave spermicide in place for at least 24 hours.
- D. Apply spermicide after intercourse.
Correct Answer: A
Rationale: Spermicide should be applied 10-30 minutes before intercourse for optimal effectiveness. It is not most effective alone, should not be left for 24 hours, and is applied before, not after, intercourse.
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The cervix of a 15-year-old primigravid client admitted to the labor area is 2 cm dilated and 50% effaced. Her membranes are intact, and contractions are occurring every 5 to 6 minutes. Which of the following should the nurse recommend at this time?
- A. Resting in the right lateral recumbent position.
- B. Using in the left lateral recumbent position.
- C. Walking around in the hallway.
- D. Sitting in a comfortable chair for a period of time.
Correct Answer: C
Rationale: In early labor (2 cm dilation), ambulation (walking) promotes labor progression by using gravity to encourage fetal descent and enhance contractions. Lateral positions are better for rest or later stages, and sitting may not aid progression as effectively.
A primigravid client with insulin-dependent diabetes tells the nurse that the contraction stress test performed earlier in the day was suspicious. The nurse interprets this test result as indicating that the fetal heart rate pattern showed which of the following?
- A. Frequent late decelerations.
- B. Decreased fetal movement.
- C. Inconsistent late decelerations.
- D. Lack of fetal movement.
Correct Answer: C
Rationale: Suspicious results indicate inconsistent late decelerations.
The nurse is caring for a primigravid client in active labor who has had two fetal blood samplings to check for fetal hypoxia. The nurse determines that the fetus is showing signs of acidosis when the scalp blood pH is below which of the following?
- A. 7.5.
- B. 7.4.
- C. 7.3.
- D. 7.2.
Correct Answer: D
Rationale: A fetal scalp blood pH below 7.2 indicates acidosis, suggesting fetal hypoxia and the need for intervention. Values above 7.25 are typically reassuring, and 7.2–7.25 may warrant close monitoring.
Which of the following nursing diagnoses would be the priority for a multigravid diabetic client at 38 weeks' gestation who is scheduled for labor induction with oxytocin (Pitocin)?
- A. Risk for deficient fluid volume related to oxytocin infusion.
- B. Pain related to prolonged labor and uterine ischemia.
- C. Fear related to possible need for cesarean delivery.
- D. Risk for injury, maternal or fetal, related to potential uterine hyperstimulation.
Correct Answer: D
Rationale: Oxytocin can cause uterine hyperstimulation, risking maternal or fetal injury (e.g., fetal hypoxia). This is the priority in a diabetic client due to increased fetal vulnerability. Fluid volume, pain, and fear are less immediate.
The nurse makes a home visit to a 3-day-old full-term neonate who weighed 3,912 grams (8 lb, 10 oz) at birth. Today the neonate, who is being bottle-fed, weighs 1,350 grams (7 lb, 14 oz).Which of the following instructions should the nurse give to the mother?
- A. Continue feeding every 3 to 4 hours since the weight loss is normal.
- B. Contact the physician if the weight loss continues over the next few days.
- C. Switch to a soy-based formula because the current one seems inadequate.
- D. Change to a higher-calorie formula to prevent further weight loss.
Correct Answer: A
Rationale: The weight loss from 3,912 g to 3,550 g (7 lb, 14 oz) is approximately 9%, which is within the normal range of up to 10% for newborns in the first few days. Continuing regular feedings is appropriate.