Nokea
A primiparous client has just delivered her baby. The physician has informed the labor nurse that he believes the uterus has inverted. Which of the following would help to confirm this diagnosis? Select all that apply.
- A. Hypotension.
- B. Gush of blood from the vagina.
- C. Intense, severe, tearing type of abdominal pain.
- D. Uterus is hard and in a constant state of contraction.
- E. Inability to palpate the uterus.
- F. Diaphoresis.
Correct Answer: A,E
Rationale: Uterine inversion is characterized by the uterus turning inside out, often leading to hypotension (due to shock) and inability to palpate the fundus abdominally. A gush of blood may occur but is not specific, severe pain is less common, the uterus is not typically hard, and diaphoresis is a secondary symptom.
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The nurse is caring for a neonate at 38 weeks' gestation when the nurse observes marked peristaltic waves on the neonate's abdomen. After this observation, the neonate exhibits projectile vomiting. The nurse notifies the pediatrician because these signs are indicative of which of the following?
- A. Esophageal atresia.
- B. Pyloric stenosis.
- C. Diaphragmatic hernia.
- D. Hiatal hernia.
Correct Answer: B
Rationale: Marked peristaltic waves and projectile vomiting are classic signs of pyloric stenosis, a condition involving hypertrophy of the pylorus muscle.
A nurse is discussing the copper IUD with a client. Which of the following client statements indicates understanding?
- A. The copper IUD is effective for up to 10 years.
- B. The copper IUD prevents ovulation.
- C. The copper IUD reduces menstrual bleeding.
- D. The copper IUD requires daily insertion.
Correct Answer: A
Rationale: The copper IUD is effective for up to 10 years, providing long-term contraception. It does not prevent ovulation, may increase menstrual bleeding, and does not require daily insertion.
Which of the following would the nurse include in the teaching plan for a primiparous client about the frequency of breast-feeding the neonate during the first few days?
- A. Feeding the neonate whenever he or she cries.
- B. Restricting feedings to 1 to 2 minutes per side.
- C. Feeding the neonate for at least 10 minutes per side.
- D. Maintaining feeding for 20 to 30 minutes per side.
Correct Answer: C
Rationale: Feeding for at least 10 minutes per side ensures adequate milk transfer and stimulation of milk production.
A nurse is teaching a client about the use of male condoms. Which of the following instructions should the nurse include?
- A. Use a water-based lubricant with latex condoms.
- B. Store condoms in a hot environment to maintain flexibility.
- C. Apply the condom after ejaculation for best results.
- D. Reuse condoms if they are undamaged.
Correct Answer: A
Rationale: Using a water-based lubricant with latex condoms prevents breakage and enhances comfort. Condoms should be stored in a cool, dry place, applied before any genital contact, and never reused.
On the first postpartum day, the primiparous client reports perineal pain of 5 on a scale of 1 to 10 that was unrelieved by ibuprofen 800 mg given 2 hours ago. The nurse should further assess the client for:
- A. Puerperal infection.
- B. Vaginal lacerations.
- C. History of drug abuse.
- D. Perineal hematoma.
Correct Answer: D
Rationale: Persistent perineal pain unrelieved by ibuprofen suggests a perineal hematoma, which requires further assessment.