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During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she has been experiencing breast engorgement. To relieve engorgement, the nurse teaches the client that before nursing her baby, the client should do which of the following?
- A. Apply an ice cube to the nipples.
- B. Rub her nipples gently with lanolin cream.
- C. Express a small amount of breast milk.
- D. Offer the neonate a small amount of formula.
Correct Answer: C
Rationale: Expressing a small amount of milk softens the breast, making it easier for the neonate to latch.
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A 19-year-old primigravid client at 38 weeks' gestation is admitted to the hospital in active labor that began 8 hours ago. When the client's cervix is 7 cm dilated and the presenting part is at +1 station, the client tells the nurse, 'I need to push!' Which of the following would the nurse do next?
- A. Use the McDonald procedure to widen the pelvic opening.
- B. Increase the rate of oxygen and intravenous fluids.
- C. Tell the client to use a pant-blow pattern of breathing.
- D. Tell the client to push only when absolutely necessary.
Correct Answer: C
Rationale: At 7 cm dilation, the client is not fully dilated, and pushing can cause cervical trauma. A pant-blow breathing pattern helps manage the urge to push until full dilation. The McDonald procedure is for cervical cerclage, and increasing oxygen/fluids or encouraging pushing is inappropriate.
A nurse is walking down the hall in the main corridor of a hospital. The Code Pink infant security alert system sounds and a Code Pink alert is announced. The first responsibility of the nurse when this situation occurs is to do which of the following?
- A. Move to the entrance of the hospital and check each person leaving.
- B. Go to the obstetrics unit to determine if they need help with the situation.
- C. Call the nursery to ask which baby is missing.
- D. Observe individuals in the area for large bags or oversized coats.
Correct Answer: D
Rationale: Observing for suspicious items like large bags helps identify potential abductors during a Code Pink.
A client is admitted with a suspected abruptio placentae. The nurse should assess the client for which of the following signs and symptoms? Select all that apply.
- A. A bleeding that is concealed or apparent.
- B. Abdominal rigidity.
- C. Painful abdomen.
- D. Painless bleeding.
- E. Large placenta.
- F. Bleeding that stops spontaneously.
Correct Answer: A,B,C
Rationale: Abruptio placentae involves placental separation, causing concealed or apparent bleeding, abdominal rigidity, and pain due to uterine irritation. Painless bleeding is characteristic of placenta previa, and large placenta or spontaneous cessation are not typical.
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 primigravid client at 38 weeks' gestation is admitted to the labor suite in active labor. The client's physical assessment reveals a chlamydial infection. The nurse explains that if the infection is left untreated, the neonate may develop which of the following?
- A. Conjunctivitis.
- B. Heart disease.
- C. Skin lesions.
- D. Hepatitis.
Correct Answer: A
Rationale: Untreated chlamydia during delivery can cause neonatal conjunctivitis (ophthalmia neonatorum) via transmission through the birth canal. Heart disease, skin lesions, and hepatitis are not associated with chlamydia.