Nokea
At which of the following locations would the nurse expect to palpate the fundus of a primiparous client immediately after delivery of a neonate?
- A. Halfway between the umbilicus and the symphysis.
- B. At the level of the umbilicus.
- C. Just below the level of the umbilicus.
- D. Above the level of the umbilicus.
Correct Answer: B
Rationale: Immediately after delivery, the fundus is typically at the level of the umbilicus due to the uterus beginning to involute.
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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.
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.
Which of the following nursing diagnoses is the priority after delivery for a multiparous client who received an epidural anesthetic?
- A. Pain related to episiotomy and exhaustive pushing efforts.
- B. Anxiety related to inability to move legs and toes.
- C. Risk for injury related to epidural anesthesia.
- D. Excess fluid volume overload related to labor process and intravenous fluids.
Correct Answer: C
Rationale: Epidural anesthesia poses a risk for injury due to potential complications like hypotension or impaired mobility, making this the priority post-delivery. Pain, anxiety, and fluid overload are secondary concerns.
While the nurse is preparing to assist the primiparous client to the bathroom to void 6 hours after a vaginal delivery under epidural anesthesia, the client says that she feels dizzy when sitting up on the side of the bed. The nurse explains that this is most likely caused by which of the following?
- A. Effects of the anesthetic during labor.
- B. Hemorrhage during the delivery process.
- C. Effects of analgesics used during labor.
- D. Decreased blood volume in the vascular system.
Correct Answer: A
Rationale: Dizziness when sitting up is likely due to residual effects of epidural anesthesia, which can cause orthostatic hypotension.
A nurse is teaching a client about the use of a cervical cap. Which of the following instructions should the nurse include?
- A. Leave the cervical cap in place for at least 6 hours after intercourse.
- B. Insert the cervical cap at least 1 hour before intercourse.
- C. Reuse the cervical cap without cleaning.
- D. Apply the cervical cap to the vaginal wall.
Correct Answer: A
Rationale: The cervical cap should be left in place for at least 6 hours after intercourse to ensure effectiveness. It can be inserted up to 6 hours before intercourse, must be cleaned after use, and is applied over the cervix, not the vaginal wall.