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During a shift change, the nurse is assigned a new postpartum client who delivered 6 hours ago. Which task should the nurse prioritize?
- A. Perform a fundal assessment.
- B. Educate the client on newborn care.
- C. Assist with breastfeeding initiation.
- D. Administer a prescribed stool softener.
Correct Answer: A
Rationale: Fundal assessment is critical within the first 24 hours to detect complications like hemorrhage.
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Which of the following nursing diagnoses would be the priority for a multigravid diabetic client at 38 weeks' gestation who is scheduled for labor induction with oxytocin (Pitocin)?
- A. Risk for deficient fluid volume related to oxytocin infusion.
- B. Pain related to prolonged labor and uterine ischemia.
- C. Fear related to possible need for cesarean delivery.
- D. Risk for injury, maternal or fetal, related to potential uterine hyperstimulation.
Correct Answer: D
Rationale: Oxytocin can cause uterine hyperstimulation, risking maternal or fetal injury (e.g., fetal hypoxia). This is the priority in a diabetic client due to increased fetal vulnerability. Fluid volume, pain, and fear are less immediate.
Shortly after birth, the nurse measures the circumference of a term neonate's head and chest. When the two measurements are compared, which of the following would the nurse expect to find about the head circumference?
- A. Equal to the chest circumference.
- B. Approximately $2 \mathrm{~cm}$ larger than the chest.
- C. About $3 \mathrm{~cm}$ smaller than the chest.
- D. Approximately $4 \mathrm{~cm}$ larger than the chest.
Correct Answer: B
Rationale: In a term neonate, the head circumference is typically about 2 cm larger than the chest circumference.
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.
Which of the following would the nurse include in the primiparous client's discharge teaching plan about measures to provide visual stimulation for the neonate?
- A. Maintain eye contact while talking to the baby.
- B. Paint the baby's room in bright colors accented with teddy bears.
- C. Use brightly colored animals and cartoon figures on the wall.
- D. Move a brightly colored rattle in front of the baby's eyes.
Correct Answer: A
Rationale: Maintaining eye contact promotes visual stimulation and bonding, suitable for a neonate's developmental stage.
After giving instruction about the cause of the vaginal bleeding to a multigravid client at 36 weeks' gestation diagnosed with placenta previa, the nurse determines that the teaching has been effective when the client says that the bleeding results from which of the following?
- A. Diminished clotting factors.
- B. Exposure of maternal blood sinuses.
- C. Increased platelet levels.
- D. A large-for-gestational-age fetus.
Correct Answer: B
Rationale: Placenta previa involves exposure of maternal blood sinuses.