Nokea
After giving instruction about the cause of the vaginal bleeding to a multigravid client at 36 weeks' gestation diagnosed with placenta previa, the nurse determines that the teaching has been effective when the client says that the bleeding results from which of the following?
- A. Diminished clotting factors.
- B. Exposure of maternal blood sinuses.
- C. Increased platelet levels.
- D. A large-for-gestational-age fetus.
Correct Answer: B
Rationale: Placenta previa involves exposure of maternal blood sinuses.
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The nurse makes a home visit to a 3-day-old full-term neonate who weighed 3,912 grams (8 lb, 10 oz) at birth. Today the neonate, who is being bottle-fed, weighs 1,350 grams (7 lb, 14 oz).Which of the following instructions should the nurse give to the mother?
- A. Continue feeding every 3 to 4 hours since the weight loss is normal.
- B. Contact the physician if the weight loss continues over the next few days.
- C. Switch to a soy-based formula because the current one seems inadequate.
- D. Change to a higher-calorie formula to prevent further weight loss.
Correct Answer: A
Rationale: The weight loss from 3,912 g to 3,550 g (7 lb, 14 oz) is approximately 9%, which is within the normal range of up to 10% for newborns in the first few days. Continuing regular feedings is appropriate.
A multigravid client at 34 weeks' gestation visits the hospital because she suspects that her water has broken. After testing the leaking fluid with nitrazine paper, the nurse confirms that the client's membranes have ruptured when the paper turns which of the following colors?
- A. Yellow.
- B. Green.
- C. Blue.
- D. Red.
Correct Answer: C
Rationale: Nitrazine paper turns blue in the presence of amniotic fluid.
A multigravid client is admitted to the labor area from the emergency room. At the time of admission, the fetal head is crowning, and the client yells, 'The baby's coming!' To help the client remain calm and cooperative during the imminent delivery, which of the following responses by the nurse is most appropriate?
- A. You're right, the baby is coming, so just relax.'
- B. Please don't push because you'll tear your cervix.'
- C. Your doctor will be here as soon as possible.'
- D. I'll explain what's happening to guide you as we go along.'
Correct Answer: D
Rationale: Explaining the process and guiding the client during a precipitous delivery promotes cooperation and reduces anxiety. Telling her to relax is unhelpful, warning against pushing is inaccurate (cervix is fully dilated), and focusing on the doctor's arrival is irrelevant.
The cervix of a 15-year-old primigravid client admitted to the labor area is 2 cm dilated and 50% effaced. Her membranes are intact, and contractions are occurring every 5 to 6 minutes. Which of the following should the nurse recommend at this time?
- A. Resting in the right lateral recumbent position.
- B. Using in the left lateral recumbent position.
- C. Walking around in the hallway.
- D. Sitting in a comfortable chair for a period of time.
Correct Answer: C
Rationale: In early labor (2 cm dilation), ambulation (walking) promotes labor progression by using gravity to encourage fetal descent and enhance contractions. Lateral positions are better for rest or later stages, and sitting may not aid progression as effectively.
The client is breast-feeding and asks the nurse about nutrition and diet. Which of the following statements by the client indicate understanding of dietary needs to promote successful breastfeeding? Select all that apply.
- A. I need to increase the number of meals I eat from three to five each day.
- B. I have to add about 500 more calories to my diet while I breast-feed.
- C. I need at least two servings of protein, like meat or eggs, with each meal.
- D. I need to double my fluids from my normal three to six glasses each day.
- E. I can eat more cheese and drink orange juice with calcium to increase my calcium intake.
Correct Answer: B,E
Rationale: An additional 500 calories and increased calcium intake are correct for breastfeeding; the other statements are inaccurate or excessive.