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After instructing a multigravid client diagnosed with mild preeclampsia how to keep a record of fetal movement patterns at home, the nurse determines that the teaching has been effective when the client says that she will count the number of times the baby moves during which of the following time spans?
- A. 30-minute period three times a day.
- B. 45-minute period after lunch each day.
- C. 1-hour period each day.
- D. 12-hour period each week.
Correct Answer: C
Rationale: Counting fetal movements for one hour daily is a common method to monitor fetal well-being.
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Assessment of a 16-year-old nulligravid client who visits the clinic and asks for information on contraceptives reveals a menstrual cycle of 28 days. The nurse formulates a nursing diagnosis of Deficient knowledge related to ovulation and fertility management. Which of the following would be important to include in the teaching plan for the client?
- A. The ovum survives for 96 hours after ovulation, making conception possible during this time.
- B. The basal body temperature falls at least 0.2°F after ovulation has occurred.
- C. Ovulation usually occurs on day 14, plus or minus 2 days, before the onset of the next menstrual cycle.
- D. Most women can tell they have ovulated because of severe pain and thick, scant cervical mucus.
Correct Answer: C
Rationale: Ovulation typically occurs around day 14 (plus or minus 2 days) before the next menstrual cycle in a 28-day cycle, which is critical for understanding fertility windows. The ovum survives for about 12-24 hours, not 96 hours, and basal body temperature rises after ovulation.
A multigravid client is admitted at 4-cm dilation and requesting pain medication. The nurse gives the client Nubain 15 mg and Phenergan 25 mg slow I.V. push. Within 5 minutes, the client tells the nurse she feels like she needs to have a bowel movement. The nurse should first:
- A. Have naloxone hydrochloride (Narcan) available in the delivery room.
- B. Perform a vaginal examination to determine dilation, effacement, and station.
- C. Prepare for delivery.
- D. Document the client's relief due to pain medication.
Correct Answer: B
Rationale: A sudden urge to have a bowel movement in labor often indicates rapid progression to full dilation or fetal descent. A vaginal examination confirms dilation and station to guide next steps (e.g., preparing for delivery). Naloxone, preparation, or documentation are premature without assessment.
Which of the following measures would the nurse expect to include in the teaching plan for a multiparous client who delivered 24 hours ago and is receiving intravenous antibiotic therapy for cystitis?
- A. Limiting fluid intake to 1 L daily to prevent overload.
- B. Catheterizing the bladder every 2 to 4 hours while awake.
- C. Washing the perineum with povidone iodine (Betadine) after voiding.
- D. Avoiding the intake of acidic fruit juices until the treatment is discontinued.
Correct Answer: D
Rationale: Avoiding acidic juices reduces bladder irritation during cystitis treatment.
A primiparous client asks how to store breast milk safely at room temperature. The nurse should instruct the client that breast milk can be left at room temperature for up to:
- A. 2 hours.
- B. 4 hours.
- C. 6 hours.
- D. 8 hours.
Correct Answer: C
Rationale: Breast milk is safe at room temperature (up to 77°F) for up to 6 hours, minimizing bacterial growth.
A nurse is discussing the copper IUD with a client. Which of the following side effects should the nurse mention?
- A. Decreased menstrual bleeding.
- B. Increased menstrual bleeding and cramping.
- C. Permanent infertility.
- D. Guaranteed regular periods.
Correct Answer: B
Rationale: The copper IUD may increase menstrual bleeding and cramping, especially initially. It does not decrease bleeding, cause permanent infertility, or guarantee regular periods.