Nokea
A primiparous client who delivered 12 hours ago under epidural anesthesia with a midline episiotomy tells the nurse that she is experiencing a great deal of discomfort when she sits in a chair with the baby. Which of the following instructions would be most appropriate?
- A. Ask for some pain medication before you sit down.
- B. Squeeze your buttock muscles together before sitting down.
- C. Keep a relaxed posture before sitting down with the possibility of the nurse.
- D. Ask the physician for some analgesic cream or spray.
Correct Answer: B
Rationale: Squeezing buttock muscles before sitting reduces pressure on the episiotomy site, alleviating discomfort.
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A nurse is discussing the contraceptive sponge with a client. Which of the following client statements indicates understanding?
- A. I need to insert the sponge at least 1 hour before intercourse.
- B. The sponge can be left in place for up to 24 hours.
- C. The sponge is more effective after childbirth.
- D. The sponge protects against HIV.
Correct Answer: B
Rationale: The contraceptive sponge can be left in place for up to 24 hours, providing flexibility. It should be inserted just before intercourse (not 1 hour prior), is less effective after childbirth, and does not protect against HIV.
The nurse is teaching a group of women about fertility awareness methods of contraception. Which of the following would the nurse include as the most reliable indicator that ovulation has occurred?
- A. A slight drop followed by a rise in basal body temperature.
- B. A change in cervical mucus to thin, clear, and stretchy.
- C. The onset of mittelschmerz, or midcycle pelvic pain.
- D. The presence of a thick, cloudy cervical mucus.
Correct Answer: A
Rationale: A slight drop followed by a rise in basal body temperature is the most reliable indicator of ovulation, as it reflects the hormonal shift post-ovulation. Cervical mucus changes and mittelschmerz are less precise, and thick mucus typically occurs post-ovulation.
A client with pregnancy-induced hypertension is to receive magnesium sulfate to run at 3 grams per hour with normal saline to maintain the total I.V. rate at 125 mL/hour. The nurse giving end of shift report stated the client's blood pressures have been elevated during the night. The oncoming nurse checked the client and found magnesium sulfate running at 2 grams per hour. Identify the nursing actions to be taken from first to last.
- A. Correct the I.V. rates to magnesium sulfate running at 3 grams/hour and normal saline to complete total rate at 125 mL/hour.
- B. Initiate an incident report.
- C. Assess the client's current status.
- D. Notify the physician of the incident.
Correct Answer: C,A,D,B
Rationale: Assess the client first, correct the error, notify the physician, and then document the incident.
A client delivered 2 days ago and has been given instructions on breast care for bottle-feeding mothers. Which of the following statements indicates that the nurse should reinforce the instructions to the client?
- A. I will wear a sports bra or a well fitting bra for several days.
- B. When showering, I'll direct water onto my shoulders.
- C. I will only use only water to clean my nipples.
- D. I will use a breast pump to remove any milk that may appear.
Correct Answer: D
Rationale: Using a breast pump can stimulate milk production, which is counterproductive for bottle-feeding mothers.
A primiparous client, who has just delivered a healthy term neonate after 12 hours of labor, holds and looks at her neonate and begins to cry. The nurse interprets this behavior as a sign of which of the following?
- A. Disappointment in the baby's gender.
- B. Grief over the ending of the pregnancy.
- C. A normal response to the birth.
- D. Indication of postpartum 'blues.'
Correct Answer: C
Rationale: Crying after delivery is a normal emotional response to the intense experience of birth, reflecting joy, relief, or overwhelming emotions. It does not indicate disappointment, grief, or postpartum blues, which typically manifest later.