Nokea
A nurse is discussing preterm labor in a prenatal class. After class, a client and her partner ask the nurse to identify again the nursing strategies to prevent preterm labor. The clients need further instruction when they state which of the following?
- A. "I need to stay hydrated all the time."
- B. "I need to avoid any infections."
- C. "I should include frequent rest breaks if we travel."
- D. "Changing to filter cigarettes is helpful."
Correct Answer: D
Rationale: Smoking, even with filter cigarettes, is harmful and should be avoided.
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A primigravid client's baseline blood pressure at her initial visit at 12 weeks' gestation was 110/70 mm Hg. During an assessment at 38 weeks' gestation, which of the following data would indicate mild preeclampsia?
- A. Blood pressure of 160/110 mm Hg on two separate occasions.
- B. Proteinuria, more than 5 g in 24 hours.
- C. Serum creatinine concentration of 1.4 mL/dL.
- D. Weight gain of 2 lb in the last week.
Correct Answer: D
Rationale: Sudden weight gain is characteristic of mild preeclampsia.
A primiparous client asks the nurse about resuming exercise after vaginal delivery. The nurse should advise the client to start low-impact exercises:
- A. Immediately after discharge.
- B. After 2 weeks postpartum.
- C. After 6 weeks postpartum.
- D. When lochia has completely stopped.
Correct Answer: C
Rationale: Low-impact exercises are generally safe after 6 weeks, allowing time for healing and recovery.
Assessment of a 23-year-old primigravid client at term who is admitted to the birthing unit in active labor reveals that her cervix is 4 cm dilated and 100% effaced. Contractions are occurring every 4 minutes. The nurse is developing a care plan with the client to relieve pain based on the gate-control theory of pain. The nurse should explain which of the following to the client?
- A. Input from the large sensory fibers opens the gate.
- B. Labor pain is a matter of individual perception.
- C. Slow abdominal breathing can open the gate.
- D. The gating mechanism is in the spinal cord.
Correct Answer: D
Rationale: The gate-control theory posits that pain signals are modulated in the spinal cord, where non-painful stimuli (e.g., touch) can 'close the gate' to pain transmission. Input from large fibers closes the gate, perception varies but is not the mechanism, and slow breathing helps manage pain but does not open the gate.
A primigravid client in active labor with a fetus in LOP position complains of severe back pressure. Which of the following would be the priority nursing diagnosis for this client?
- A. Anxiety related to fear of maternal-fetal outcomes.
- B. Ineffective coping related to lack of experience in labor.
- C. Urinary retention related to prolonged labor process.
- D. Pain related to occipitoposterior position and prolonged fetal descent.
Correct Answer: D
Rationale: Severe back pain due to the LOP position is a priority, as it impacts the client's comfort and labor experience. Pain management (e.g., counterpressure) is critical. Anxiety, coping, and urinary retention are secondary concerns.
A multiparous client, 28 hours after cesarean delivery, who is breast-feeding complains of severe cramps or afterpains. The nurse explains that these are caused by which of the following?
- A. Flatulence accumulation after a cesarean delivery.
- B. Healing of the abdominal incision after cesarean delivery.
- C. Adverse effects of the medications administered after delivery.
- D. Release of oxytocin during the breast-feeding session.
Correct Answer: D
Rationale: Breastfeeding stimulates oxytocin release, causing uterine contractions (afterpains) as the uterus involutes.