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Assessment of a primigravid client in active labor who has had no analgesia or anesthesia reveals complete cervical effacement, dilation of 8 cm, and the fetus at 0 station. The nurse should expect the client to exhibit which of the following behaviors during this phase of labor?
- A. Excitement.
- B. Loss of control.
- C. Numbness of the legs.
- D. Feelings of relief.
Correct Answer: B
Rationale: During the transition phase (8–10 cm dilation), primigravid clients without analgesia often experience intense contractions and may feel overwhelmed, leading to a perceived loss of control. Excitement is more common in early labor, numbness of the legs is associated with epidural anesthesia, and feelings of relief typically occur after delivery.
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A nurse is discussing the contraceptive injection with a client. Which of the following benefits should the nurse highlight?
- A. It provides protection against STIs.
- B. It is effective for 3 months per injection.
- C. It requires daily administration.
- D. It guarantees regular periods.
Correct Answer: B
Rationale: The contraceptive injection is effective for 3 months per injection, offering convenient long-term contraception. It does not protect against STIs, is not administered daily, and may cause irregular periods.
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 in active labor has been diagnosed with class II heart disease and has had a prosthetic valve replacement. When developing the plan of care for this client, the nurse should anticipate that the physician most likely will order which of the following medications?
- A. Anticoagulants.
- B. Antibiotics.
- C. Diuretics.
- D. Folic acid supplements.
Correct Answer: B
Rationale: Prosthetic heart valves increase the risk of endocarditis during labor due to bacteremia. Prophylactic antibiotics are typically ordered. Anticoagulants may be adjusted, but antibiotics are prioritized during labor.
An obese 36-year-old multigravid client at 12 weeks' gestation has a history of chronic hypertension. She was treated with methyldopa(Aldomet) before becoming pregnant. When counseling the client about diet during pregnancy, the nurse realizes that the client needs additional instruction when she states which of the following?
- A. "I need to reduce my caloric intake to 1,200 calories a day."
- B. "A regular diet is recommended during pregnancy."
- C. "I should eat more frequent meals if I get heartburn."
- D. "I need to consume more fluids and fiber each day."
Correct Answer: A
Rationale: Reducing caloric intake too much can be harmful during pregnancy.
A client who is planning a pregnancy asks the nurse about the use of herbal supplements to enhance fertility. Which of the following responses by the nurse is most appropriate?
- A. Herbal supplements are safe and effective for enhancing fertility.
- B. Consult with your health care provider before taking any herbal supplements.
- C. Herbal supplements can replace prenatal vitamins during pregnancy.
- D. Most herbal supplements are regulated by the FDA for safety.
Correct Answer: B
Rationale: Herbal supplements can interact with medications or affect pregnancy, so consulting a healthcare provider is essential. They are not proven safe or effective for fertility, not a substitute for prenatal vitamins, and are not tightly regulated by the FDA.