Nokea
A primiparous client, 4 hours postpartum, reports feeling overwhelmed and anxious about caring for her newborn. Which nursing intervention is most appropriate?
- A. Encourage the client to rest and limit visitors.
- B. Teach the client basic newborn care skills immediately.
- C. Administer an anxiolytic medication as prescribed.
- D. Refer the client to a social worker for counseling.
Correct Answer: B
Rationale: Teaching basic newborn care skills empowers the client, reduces anxiety, and promotes confidence in the early postpartum period.
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While assessing the episiotomy site of a primiparous client on the first postpartum day, the nurse observes a fairly large hemorrhoid at the client's rectum. After instructing the client about measures to relieve hemorrhoid discomfort, which of the following client statements indicates the need for additional teaching?
- A. I should try to gently manually replace the hemorrhoid.
- B. Analgesic sprays and witch hazel pads can relieve the pain.
- C. I should lie on my back as much as possible to relieve the pain.
- D. I should drink lots of water and eat foods that have a lot of roughage.
Correct Answer: C
Rationale: Lying on the back increases pressure on hemorrhoids, worsening discomfort; the other statements reflect correct measures.
A client asks about the differences between the copper IUD and the hormonal IUD. Which of the following responses by the nurse is accurate?
- A. The copper IUD is hormone-free and may increase menstrual bleeding, while the hormonal IUD may reduce bleeding.
- B. Both IUDs require replacement every year.
- C. The copper IUD prevents ovulation, while the hormonal IUD does not.
- D. The hormonal IUD is less effective than the copper IUD.
Correct Answer: A
Rationale: The copper IUD is hormone-free and may increase menstrual bleeding, while the hormonal IUD releases progestin and may reduce bleeding. Both last several years, neither primarily prevents ovulation, and both are highly effective.
A primigravid client at 37 weeks' gestation with gestational diabetes is in active labor at 5 cm dilation. The nurse notes a blood glucose level of 45 mg/dL. What is the nurse's first action?
- A. Administer 50% dextrose IV push.
- B. Offer the client a high-carbohydrate snack.
- C. Recheck the blood glucose level.
- D. Notify the physician of the result.
Correct Answer: B
Rationale: A blood glucose of 45 mg/dL indicates maternal hypoglycemia, common in gestational diabetes due to insulin use. Offering a high-carbohydrate snack is the first action to stabilize glucose safely. Dextrose is for severe cases, rechecking delays treatment, and notification follows initial management.
A 24-year-old client is discussing contraception options with the nurse and expresses interest in an intrauterine device (IUD). Which of the following statements by the client indicates a need for further teaching?
- A. I understand the IUD can remain in place for several years.
- B. The IUD will prevent ovulation each month.
- C. I may experience heavier menstrual periods with the copper IUD.
- D. The IUD does not protect against sexually transmitted infections.
Correct Answer: B
Rationale: The IUD does not primarily prevent ovulation; it works by affecting sperm movement and preventing fertilization (copper IUD) or thinning the uterine lining (hormonal IUD). The other statements are correct, indicating a need for further teaching about its mechanism.
A 16-year-old unmarried primigravid client at 37 weeks' gestation with severe preeclampsia is in early active labor. Her mother is at the bedside. The client's blood pressure is 164/110 mm Hg. Which of the following would alert the nurse that the client may be about to experience a seizure?
- A. Decreased contraction intensity.
- B. Decreased temperature.
- C. Epigastric pain.
- D. Hyporeflexia.
Correct Answer: C
Rationale: Epigastric pain is a warning sign of impending eclampsia.