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An LPN asks an RN to assist in locating the fundus of the client who is 8 hours post—vaginal delivery. Place an X at the location on the client’s abdomen where the RN should direct the LPN to begin to palpate the fundus.
Correct Answer: Level of the umbilicus
Rationale: Six to 12 hours after birth, the fundus of the uterus rises to the level of the umbilicus due to blood and clots that remain within the uterus and changes in ligament support. Thus, the RN should direct the LPN to locate the client’s fundus at the level of the umbilicus.
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Using Naegele's Rule, the nurse can assume the client's expected delivery date to be approximately which date?
- A. 13-Nov
- B. 23-Nov
- C. 3-Dec
- D. 20-Dec
Correct Answer: C
Rationale: Naegele's Rule: Subtract 3 months from the first day of the last menstrual period (March 13) and add 7 days, resulting in December 3.
The nurse considers prenatal teaching successful when the class correctly identifies which of the following as a danger sign of pregnancy?
- A. Headache and swelling of the face and fingers
- B. Constipation and flatulence on a regular basis
- C. Lower extremity muscle cramping and varicosities
- D. Large amounts of odorless, colorless vaginal secretions
Correct Answer: A
Rationale: Headache and swelling of the face and fingers may indicate preeclampsia, a serious condition requiring immediate attention.
Which response by the nurse about Chadwick's sign is most accurate?
- A. It's a bluish discoloration of the cervix, vagina, and vulva that occurs as a result of the presence of an increased number of blood vessels.
- B. It's a softening of the cervix that occurs because of an increased amount of blood flowing to the reproductive organs.
- C. It's a dark brown line extending from the umbilicus to the symphysis pubis that occurs as a result of hormonal changes.
- D. None of the above
Correct Answer: A
Rationale: Chadwick's sign is the bluish discoloration of the cervix, vagina, and vulva due to increased vascularity, a probable sign of pregnancy.
To improve sperm production, the nurse should instruct the client's husband to avoid which activities? Select all that apply.
- A. Swimming in chlorinated water
- B. Sitting in hot tubs
- C. Wearing boxer shorts
- D. Wearing colored underwear
- E. Smoking cigarettes
- F. Refraining from strenuous exercise
Correct Answer: B,E
Rationale: High temperatures from hot tubs can impair sperm production by overheating the testes. Smoking cigarettes negatively affects sperm quality and quantity.
The client on the labor unit has been experiencing frequent, painful contractions for the last 6 hours. The contractions are of poor quality, and there has been no cervical change. Which interventions should the nurse implement? Select all that apply.
- A. Maintain bed rest
- B. Administer a sedative
- C. Administer an analgesic
- D. Prepare for cesarean delivery
- E. Prepare to start oxytocin
Correct Answer: A,B,C,E
Rationale: This client is experiencing a hypertonic labor pattern in which her contractions are frequent and painful, but no cervical change has occurred. This client should be encouraged to rest often. A sedative should be given to assist the client to rest. Because the contractions are painful, an analgesic should be administered to help the client relax and cope more effectively. If the hypertonic labor pattern continues, augmentation should be initiated with either an oxytocin infusion or amniotomy. A cesarean birth is not a treatment for a hypertonic labor pattern unless a nonreassuring FHR pattern is present.