Nokea
A primiparous client who delivered vaginally 8 hours ago desires to take a shower. The nurse anticipates remaining nearby the client to assess for which of the following?
- A. Fatigue.
- B. Fainting.
- C. Diuresis.
- D. Hygiene needs.
Correct Answer: B
Rationale: Fainting is a risk during the first shower postpartum due to potential orthostatic hypotension or fatigue, requiring close monitoring.
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A client asks about the side effects of the vaginal contraceptive ring. Which of the following would the nurse include?
- A. Nausea and breast tenderness may occur.
- B. It causes permanent infertility.
- C. It requires surgical insertion.
- D. It guarantees regular periods.
Correct Answer: A
Rationale: Nausea and breast tenderness are possible side effects of the vaginal contraceptive ring, especially initially. It does not cause permanent infertility, require surgical insertion, or guarantee regular periods.
A client visits the clinic seeking a prescription for oral contraceptives. Which of the following would alert the nurse to further assess the client before the contraceptives are prescribed?
- A. The client has a history of fibrocystic breast disease.
- B. The client has a family history of ovarian cancer.
- C. The client is a smoker and 37 years old.
- D. The client experienced irregular menstrual cycles as an adolescent.
Correct Answer: C
Rationale: Smoking at age 37 is a significant risk factor for cardiovascular complications with combined oral contraceptives, requiring further assessment. Fibrocystic breast disease and irregular cycles are not contraindications, and family history of ovarian cancer is less relevant.
A nurse is discussing preterm labor in a prenatal class. After class, a client and her partner ask the nurse to identify again the nursing strategies to prevent preterm labor. The clients need further instruction when they state which of the following?
- A. "I need to stay hydrated all the time."
- B. "I need to avoid any infections."
- C. "I should include frequent rest breaks if we travel."
- D. "Changing to filter cigarettes is helpful."
Correct Answer: D
Rationale: Smoking, even with filter cigarettes, is harmful and should be avoided.
The nurse in a postpartum couplet room is making rounds prior to ending the shift. Which of the following indicate that the safety needs of the clients have been met?
- A. Infant lying on abdomen.
- B. Security tags in place.
- C. Identification system on mother and infant.
- D. Bulb syringe within sight.
- E. Someone in room able to care for infant.
- F. Infant in the mother's bed, side rails up.
- G. Infant in the mother's arms, both asleep.
Correct Answer: B,C,D,E
Rationale: Safety needs are met with security tags, identification systems, a bulb syringe for suctioning, and someone present to care for the infant.
While caring for a moderately obese primigravid client in active labor at term, the nurse should monitor the client for signs of which of the following?
- A. Hypotonic reflexes.
- B. Increased uterine resting tone.
- C. Soft tissue dystocia.
- D. Increased fear and anxiety.
Correct Answer: C
Rationale: Obesity in labor increases the risk of soft tissue dystocia due to excess pelvic fat impeding fetal descent. Hypotonic reflexes are not typically associated with obesity, increased uterine resting tone is more related to hyperstimulation, and while anxiety may occur, it is not specific to obesity-related complications.