Nokea
A primigravid client delivered vaginally 2 hours ago with no complications. As the nurse plans care for this postpartum client, which postpartum goal would have the highest priority?
- A. By discharge, the family will bond with the neonate.
- B. The client will demonstrate self-care and infant care by the end of the shift.
- C. The client will state instructions for discharge during the first postpartum day.
- D. By the end of the shift, the client will describe a safe home environment.
Correct Answer: B
Rationale: The highest priority in the immediate postpartum period is ensuring the client can perform self-care and infant care, as this promotes safety and independence, which are critical for recovery and newborn care.
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Which of the following measures would the nurse expect to include in the teaching plan for a multiparous client who delivered 24 hours ago and is receiving intravenous antibiotic therapy for cystitis?
- A. Limiting fluid intake to 1 L daily to prevent overload.
- B. Catheterizing the bladder every 2 to 4 hours while awake.
- C. Washing the perineum with povidone iodine (Betadine) after voiding.
- D. Avoiding the intake of acidic fruit juices until the treatment is discontinued.
Correct Answer: D
Rationale: Avoiding acidic juices reduces bladder irritation during cystitis treatment.
A 39-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor has been diagnosed with class II heart disease. To ensure cardiac emptying and adequate oxygenation during labor, the nurse plans to encourage the client to do which of the following?
- A. Breathe slowly after each contraction.
- B. Avoid the use of analgesics for the labor pain.
- C. Remain in a side-lying position with the head elevated.
- D. Request local anesthesia for vaginal delivery.
Correct Answer: C
Rationale: For class II heart disease, a side-lying position with head elevation reduces cardiac strain by optimizing venous return and oxygenation. Slow breathing is helpful but less specific, avoiding analgesics may increase stress, and local anesthesia is unrelated to cardiac emptying.
Initial assessment of a term female neonate about 4 hours old reveals a normal anterior fontanel. The nurse documents its shape as which of the following?
- A. Oval.
- B. Square.
- C. Diamond shaped.
- D. Triangular.
Correct Answer: C
Rationale: The anterior fontanel in a term neonate is typically diamond-shaped.
For the client who is receiving intravenous magnesium sulfate for severe preeclampsia, which of the following assessment findings would alert the nurse to suspect hypermagnesemia?
- A. Decreased deep tendon reflexes.
- B. Cool skin temperature.
- C. Rapid pulse rate.
- D. Tingling in the toes.
Correct Answer: A
Rationale: Decreased deep tendon reflexes are a sign of hypermagnesemia.
A 6-lb, 8-oz neonate was delivered vaginally at 38 weeks' gestation. At 5 minutes of life, the neonate has the following signs: heart rate 110 , intermittent grunting with respiratory rate of 70 , flaccid tone, no response to stimulus, overall pale white in color. The Apgar score is:
- A. 2
- B. 3
- C. 4
- D. 6
Correct Answer: B
Rationale: Heart rate 110 (2 points), respiratory effort with grunting (1 point), flaccid tone (0 points), no response to stimulus (0 points), pale white color (0 points). Total Apgar score = 3.