Nokea
A primigravid client in active labor has had no anesthesia. The client's cervix is 7 cm dilated, and she is starting to feel considerable discomfort during the first 10 cm to the client's sacral client is a left side-lying position. The nurse should encourage which of the following?
- A. Rapid, shallow chest breathing.
- B. Deep chest breathing.
- C. Rapid pant-blow breathing.
- D. Slow abdominal breathing.
Correct Answer: D
Rationale: Slow abdominal breathing promotes relaxation and oxygenation, helping manage discomfort in active labor without anesthesia. Rapid or shallow breathing may lead to hyperventilation, and deep chest breathing is less effective for pain control.
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A client is considering the contraceptive injection. Which of the following client statements indicates understanding?
- A. The injection is given every 3 months.
- B. The injection protects against STIs.
- C. The injection requires daily administration.
- D. The injection causes permanent infertility.
Correct Answer: A
Rationale: The contraceptive injection is given every 3 months, providing sustained contraception. It does not protect against STIs, is not taken daily, and does not cause permanent infertility.
A 24-year-old client, G 3, P 1, at 32 weeks' gestation, is admitted to the hospital because of vaginal bleeding. After reviewing the client's history, which of the following factors might lead the nurse to suspect abruptio placentae?
- A. Several hypotensive episodes.
- B. Previous low transverse cesarean delivery.
- C. One induced abortion.
- D. History of cocaine use.
Correct Answer: D
Rationale: Cocaine use is a risk factor for abruptio placentae.
A multigravid client in active labor has been diagnosed with class II heart disease and has had a prosthetic valve replacement. When developing the plan of care for this client, the nurse should anticipate that the physician most likely will order which of the following medications?
- A. Anticoagulants.
- B. Antibiotics.
- C. Diuretics.
- D. Folic acid supplements.
Correct Answer: B
Rationale: Prosthetic heart valves increase the risk of endocarditis during labor due to bacteremia. Prophylactic antibiotics are typically ordered. Anticoagulants may be adjusted, but antibiotics are prioritized during labor.
Two hours after vaginally delivering a viable male neonate under epidural anesthesia, the client with a midline episiotomy ambulates to the bathroom to void. After voiding, the nurse assesses the client's bladder, finding it distended. The nurse interprets this finding based on the understanding that the client's bladder distention is most likely caused by which of the following?
- A. Prolonged first stage of labor.
- B. Urinary tract infection.
- C. Pressure of the uterus on the bladder.
- D. Edema in the lower urinary tract area.
Correct Answer: D
Rationale: Edema in the lower urinary tract, often from delivery trauma or epidural anesthesia, can cause urinary retention and bladder distention.
A nurse is teaching a client about the withdrawal method of contraception. Which of the following statements by the nurse is accurate?
- A. The withdrawal method is highly effective when performed correctly.
- B. The withdrawal method does not protect against STIs and has a high failure rate.
- C. The withdrawal method requires medical supervision for effectiveness.
- D. The withdrawal method is more effective than condoms.
Correct Answer: B
Rationale: The withdrawal method does not protect against STIs and has a high failure rate due to pre-ejaculate containing sperm and reliance on timing. It does not require medical supervision and is less effective than condoms.