Nokea
Assessment of a 23-year-old primigravid client at term who is admitted to the birthing unit in active labor reveals that her cervix is 4 cm dilated and 100% effaced. Contractions are occurring every 4 minutes. The nurse is developing a care plan with the client to relieve pain based on the gate-control theory of pain. The nurse should explain which of the following to the client?
- A. Input from the large sensory fibers opens the gate.
- B. Labor pain is a matter of individual perception.
- C. Slow abdominal breathing can open the gate.
- D. The gating mechanism is in the spinal cord.
Correct Answer: D
Rationale: The gate-control theory posits that pain signals are modulated in the spinal cord, where non-painful stimuli (e.g., touch) can 'close the gate' to pain transmission. Input from large fibers closes the gate, perception varies but is not the mechanism, and slow breathing helps manage pain but does not open the gate.
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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.
When assessing a 34-year-old multigravid client at 34 weeks' gestation experiencing moderate vaginal bleeding, which of the following would most likely alert the nurse that placenta previa is present?
- A. Painless vaginal bleeding.
- B. Uterine tetany.
- C. Intermittent pain with spotting.
- D. Dull lower back pain.
Correct Answer: A
Rationale: Painless vaginal bleeding is characteristic of placenta previa.
After a vaginal delivery of a term neonate, the nurse observes that the neonate has one artery and one vein in the umbilical cord. The nurse notifies the pediatrician based on the analysis that this may be indicative of ?
- A. Respiratory anomalies.
- B. Musculoskeletal anomalies.
- C. Cardiovascular anomalies.
- D. Facial anomalies.
Correct Answer: C
Rationale: A single umbilical artery is associated with an increased risk of cardiovascular anomalies, warranting further evaluation.
A primiparous client who delivered a viable term neonate vaginally 48 hours ago has a midline episiotomy and a third-degree laceration. When preparing the client for discharge, which of the following assessments would be most important?
- A. Constipation.
- B. Diarrhea.
- C. Excessive bleeding.
- D. Rectal fistulas.
Correct Answer: C
Rationale: Excessive bleeding is critical to assess due to the risk of hemorrhage with a third-degree laceration.
After a dilatation and curettage(D&C) to evacuate a molar pregnancy, assessing the client for signs and symptoms of which of the following would be most important?
- A. Urinary tract infection.
- B. Hemorrhage.
- C. Abdominal distention.
- D. Chorioamnionitis.
Correct Answer: B
Rationale: Hemorrhage is a potential complication after D&C.