Nokea
A primiparous client post-cesarean asks about preventing constipation. The nurse should recommend:
- A. Limiting fluid intake to avoid bladder distention.
- B. Eating a low-fiber diet for the first week.
- C. Increasing intake of fruits and whole grains.
- D. Taking a laxative daily for 2 weeks.
Correct Answer: C
Rationale: Fruits and whole grains provide fiber, promoting regular bowel movements and preventing constipation.
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A primigravid client at 41 weeks' gestation is admitted to the hospital's labor and delivery unit in active labor. After 25 hours of labor with membranes ruptured for 24 hours, the client delivers a healthy neonate vaginally with a midline episiotomy. Which of the following nursing diagnoses should the nurse identify as the priority for the client?
- A. Activity intolerance related to difficult labor process.
- B. Sleep deprivation related to prolonged labor.
- C. Situational low self-esteem related to lengthy labor process.
- D. Risk for infection related to birth trauma and prolonged ruptured membranes.
Correct Answer: D
Rationale: Prolonged rupture of membranes (>24 hours) and episiotomy increase infection risk, making this the priority post-delivery. Activity intolerance, sleep deprivation, and self-esteem are less urgent.
A primigravid client with severe preeclampsia exhibits hyperactive, very brisk patellar reflexes with two beats of ankle clonus present. The nurse documents the patellar reflexes as which of the following?
- A. 1+.
- B. 2+.
- C. 3+.
- D. 4+.
Correct Answer: C
Rationale: Hyperactive reflexes are documented as 3+.
After conducting a class for female adolescents about human reproduction, which of the following statements indicates that the school nurse's teaching has been effective?
- A. Under ideal conditions, sperm can reach the ovum in 15 to 30 minutes, resulting in pregnancy.
- B. I won't become pregnant if I abstain from intercourse during the last 14 days of my menstrual cycle.
- C. Both of the above
- D. None of the above
Correct Answer: A
Rationale: Sperm can reach the ovum in 15-30 minutes under ideal conditions, which is accurate. Abstaining during the last 14 days of the cycle is not a reliable contraception method, as ovulation timing varies.
Following a cesarean delivery for abruptio placentae, a multigravid client tells the nurse, "I feel like such a failure. None of my other deliveries were like this." The nurse's response to the client is based on the understanding of which of the following?
- A. The client will most likely have postpartum blues.
- B. Maternal-infant bonding is likely to be difficult.
- C. The client's feeling of grief is a normal reaction.
- D. This type of delivery was necessary to save the client's life.
Correct Answer: C
Rationale: Grief is a normal reaction to a complicated delivery.
An infant born premature at 34 weeks is receiving gavage feedings. The client holding her infant asks why the nurse places a pacifier in the infant's mouth during these feedings. The nurse replies that the pacifier helps in what ways? Select all that apply.
- A. Teaches the infant to suck and swallow.
- B. Provides oral stimulation.
- C. Keeps oral mucus membranes moist while the tube is in place.
- D. Reminds the infant how to suck.
- E. Stimulates secretions that help gastric emptying.
Correct Answer: B,D
Rationale: The pacifier provides oral stimulation and reminds the infant how to suck, promoting oral motor development.