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 client asks about the risks of the hormonal IUD. Which of the following would the nurse include?
- A. Increased risk of breast cancer.
- B. Irregular bleeding, especially initially.
- C. Permanent infertility.
- D. Guaranteed regular menstrual cycles.
Correct Answer: B
Rationale: The hormonal IUD may cause irregular bleeding, especially initially, which often decreases over time. It does not increase breast cancer risk, cause permanent infertility, or guarantee regular cycles.
A primigravid client at 37 weeks' gestation has been hospitalized for several days with severe pregnancy-induced hypertension. While caring for the client, the nurse observes that the client is beginning to have a seizure. Which of the following actions should the nurse do first?
- A. Pad the side rails of the client's bed.
- B. Turn the client to the right side.
- C. Insert a padded tongue blade into the client's mouth.
- D. Call for immediate assistance in the client's room.
Correct Answer: D
Rationale: A seizure in pregnancy-induced hypertension (eclampsia) is a medical emergency. Calling for immediate assistance ensures rapid intervention (e.g., magnesium sulfate). Padding rails, repositioning, or inserting a tongue blade (which is outdated) are secondary.
A client is considering the hormonal IUD. Which of the following client statements indicates a need for further teaching?
- A. The IUD may reduce my menstrual bleeding.
- B. The IUD can stay in place for several years.
- C. The IUD will prevent ovulation every month.
- D. The IUD does not protect against STIs.
Correct Answer: C
Rationale: The hormonal IUD does not primarily prevent ovulation every month; it mainly thins the uterine lining and thickens cervical mucus. The other statements are correct, indicating a need for further teaching.
A preterm infant delivered 2 hours ago at 34 weeks' gestation is experiencing rapid respirations, grunting, no breath sounds on one side, and a shift in location of heart sounds. The nurse should prepare to assist with which of the following?
- A. Placement of the neonate on a ventilator.
- B. Administration of bronchodilators through the nurse.
- C. Suctioning of the neonate's nares with wall suction.
- D. Insertion of a chest tube into the neonate.
Correct Answer: D
Rationale: These symptoms suggest a pneumothorax, and inserting a chest tube is the priority to relieve air trapping.
An adolescent primiparous client at 24 hours postpartum tells the nurse that she and her baby will be living with her boyfriend's parents so that she can finish high school and go on to college. The client's boyfriend and parents have been supportive of the client and neonate. Which of the following is an appropriate nursing diagnosis at this time?
- A. Anxiety related to return to high school and peer pressure.
- B. Ineffective coping related to inability to view motherhood realistically.
- C. Readiness for enhanced family coping, related to the addition of a new family member.
- D. Deficient knowledge related to the financial and emotional costs of childrearing.
Correct Answer: C
Rationale: The supportive environment suggests readiness for enhanced family coping, which is appropriate given the positive family dynamics.