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During the first hour after a precipitous delivery, the nurse should monitor a multiparous client for signs and symptoms of which of the following?
- A. Postpartum 'blues.'
- B. Uterine atony.
- C. Intrauterine infection.
- D. Urinary tract infection.
Correct Answer: B
Rationale: Precipitous delivery increases the risk of uterine atony due to rapid labor, potentially causing postpartum hemorrhage. Postpartum blues, intrauterine infection, or urinary tract infection are less immediate concerns.
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After reinforcing the danger signs to report with a gravida 2 client at 32 weeks' gestation with an elevated blood pressure, which client statements would demonstrate her understanding of when to call the physician's office? Select all that apply.
- A. "If I get up in the morning and feel dizzy, even if the dizziness goes away."
- B. "If I see any bleeding, even if I have no pain."
- C. "If I have a pounding headache that doesn't go away."
- D. "If I notice the veins in my legs getting bigger."
- E. "If the leg cramps at night are waking me up."
- F. "If the baby seems to be more active than usual."
Correct Answer: A,B,C,F
Rationale: These symptoms could indicate complications needing medical attention.
An infant born premature at 34 weeks is receiving gavage feedings. The client holding her infant asks why the nurse places a pacifier in the infant's mouth during these feedings. The nurse replies that the pacifier helps in what ways? Select all that apply.
- A. Teaches the infant to suck and swallow.
- B. Provides oral stimulation.
- C. Keeps oral mucus membranes moist while the tube is in place.
- D. Reminds the infant how to suck.
- E. Stimulates secretions that help gastric emptying.
Correct Answer: B,D
Rationale: The pacifier provides oral stimulation and reminds the infant how to suck, promoting oral motor development.
A nurse is counseling a client about the use of a diaphragm. Which of the following instructions should the nurse include?
- A. Insert the diaphragm up to 12 hours before intercourse.
- B. Use spermicide with the diaphragm for each act of intercourse.
- C. Remove the diaphragm immediately after intercourse.
- D. Store the diaphragm in a hot, humid environment.
Correct Answer: B
Rationale: Using spermicide with the diaphragm for each act of intercourse is essential for effectiveness. It can be inserted up to 6 hours before intercourse, should be left in place for at least 6 hours after, and stored in a cool, dry place.
After conducting a class for female adolescents about human reproduction, which of the following statements indicates that the school nurse's teaching has been effective?
- A. Under ideal conditions, sperm can reach the ovum in 15 to 30 minutes, resulting in pregnancy.
- B. I won't become pregnant if I abstain from intercourse during the last 14 days of my menstrual cycle.
- C. Both of the above
- D. None of the above
Correct Answer: A
Rationale: Sperm can reach the ovum in 15-30 minutes under ideal conditions, which is accurate. Abstaining during the last 14 days of the cycle is not a reliable contraception method, as ovulation timing varies.
An adolescent primiparous client 24 hours postpartum asks the nurse how often she should hold her neonate. Which of the following responses would be most appropriate?
- A. Hold him when he is fussy or crying.
- B. Hold him as much as you want to hold him.
- C. Try to hold him infrequently to avoid overstimulation.
- D. You can hold him periodically throughout the day.
Correct Answer: B
Rationale: Holding the neonate as much as desired promotes bonding and emotional security without risk of overstimulation.