Nokea
During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she is aware of a "let-down sensation" in her breasts and asks what causes it. The nurse explains that the let-down sensation is stimulated by which of the following?
- A. Adrenalin.
- B. Estrogen.
- C. Prolactin.
- D. Oxytocin.
Correct Answer: D
Rationale: Oxytocin triggers the let-down reflex, releasing milk during breastfeeding.
You may also like to solve these questions
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.
The nurse has obtained a urine specimen from a G 6, P 5 client admitted to the labor unit. The woman asks to go to the bathroom and reports that she feels she has to move her bowels. Which actions would be appropriate? Select all that apply.
- A. Assisting her to the bathroom.
- B. Applying an external fetal monitor to obtain fetal heart rate.
- C. Assessing her stage of labor.
- D. Asking if she had back labor pains like this with any of her other deliveries.
- E. Allowing her support person to take her to the bathroom to maintain privacy.
- F. Checking the degree of fetal descent.
Correct Answer: C,F
Rationale: The urge to move bowels often indicates advanced labor or fetal descent in a multiparous client. Assessing the stage of labor and fetal descent (via vaginal exam) confirms progression and prevents unattended delivery. Assisting to the bathroom or relying on a support person risks delivery, and fetal monitoring or past labor history are secondary.
The nurse is caring for a primigravid client in active labor at 42 weeks' gestation. The client has had no analgesia or anesthesia and has been pushing for 2 hours. The nurse can be most helpful to this client by:
- A. Changing her pushing position every 15 minutes.
- B. Notifying the health care provider of her current status.
- C. Continuing with current pushing technique.
- D. Assessing the client's current pain and fetal status.
Correct Answer: D
Rationale: Prolonged pushing (2 hours) in a primigravid client at 42 weeks requires assessment of pain and fetal status to identify potential complications like exhaustion or fetal distress. Changing positions may help but is less urgent, notifying the provider is premature without assessment, and continuing the current technique may not address underlying issues.
A nurse is discussing the contraceptive ring with a client. Which of the following client statements indicates understanding?
- A. I can remove the ring for up to 3 hours if needed.
- B. The ring is replaced every week.
- C. The ring requires daily insertion.
- D. The ring provides long-term contraception for 5 years.
Correct Answer: A
Rationale: The vaginal contraceptive ring can be removed for up to 3 hours if needed without losing effectiveness. It is replaced every 3 weeks (not weekly), not inserted daily, and provides contraception for one cycle, not 5 years.
The physician orders scalp stimulation of the fetal head for a primigravid client in active labor. When explaining to the client about this procedure, which of the following would the nurse include as the purpose?
- A. Assessment of the fetal hematocrit level.
- B. Increase in the strength of the contractions.
- C. Increase in the fetal heart rate and variability.
- D. Assessment of fetal position.
Correct Answer: C
Rationale: Scalp stimulation is used to assess fetal well-being by eliciting a heart rate acceleration, indicating good oxygenation and variability. It does not assess hematocrit, strengthen contractions, or determine position.