Nokea
The client in active labor has moderate to strong contractions occurring every 2 minutes and lasting 60 to 70 seconds. The client states extreme pain in the small of her back. Her abdomen reveals a small depression under the umbilicus. Which fetal position should the nurse document?
- A. Occiput anterior
- B. Occiput posterior
- C. Left occiput anterior
- D. Right occiput anterior
Correct Answer: B
Rationale: An occiput posterior position is characterized by intense back pain (back labor). A depression under the umbilicus occurs as a result of the posterior shoulder. When a fetus presents anterior, it is uncommon for the mother’s chief symptom to be back pain, and the uterus should appear smooth.
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The nurse is caring for four postpartum clients. Which client should be the nurse’s priority for monitoring for uterine atony?
- A. Client who is 2 hours post-cesarean birth for a breech baby
- B. Client who delivered a macrosomic baby after a 12-hour labor
- C. Client who has a firm fundus after a vaginal delivery 4 hours ago
- D. Client receiving oxytocin intravenously for past 2 hours
Correct Answer: B
Rationale: Although the client post—cesarean birth for a breech baby may be at risk for uterine atony and should be monitored, the client who delivered a macrosomic baby is more at risk. This client is the nurse’s priority for monitoring for uterine atony. A macrosomic baby stretches the client’s uterus, and thus the muscle fibers of the myometrium, beyond the usual pregnancy size. After delivery the muscles are unable to contract effectively. A firm fundus indicates that the client’s uterine muscles are contracting. Oxytocin (Pitocin) is being administered to increase uterine contractions. Although prolonged use of oxytocin can result in uterine exhaustion, two hours of use is not prolonged.
Which client would the nurse identify as being at highest risk for developing complications during pregnancy?
- A. A 17-year-old gravida I client
- B. A client with the placenta implanted on the fundus of the uterus
- C. A client who has nausea and vomiting during the first trimester
- D. A 35-year-old gravida V client
Correct Answer: D
Rationale: A 35-year-old gravida V client is at higher risk due to advanced maternal age and multiple pregnancies, increasing complication risks.
Which resource should the nurse recommend for additional prenatal education?
- A. Reputable pregnancy websites
- B. Social media forums
- C. Unverified blogs
- D. Television advertisements
Correct Answer: A
Rationale: Reputable pregnancy websites provide evidence-based information, ensuring accurate and reliable prenatal education.
The nurse advises the client that this test is typically performed at what time during the pregnancy?
- A. Just after the pregnancy is confirmed
- B. Early in the second trimester
- C. In the transition phase of labor
- D. Just after the first fetal movements
Correct Answer: B
Rationale: Amniocentesis is typically performed early in the second trimester (15-20 weeks) to assess for genetic abnormalities.
To best enhance absorption of the iron supplement, which foods should the nurse recommend the client increase in her diet? Select all that apply.
- A. Oranges
- B. Potatoes
- C. Bananas
- D. Broccoli
- E. Whole milk
- F. Carrots
Correct Answer: A,D
Rationale: Oranges and broccoli are rich in vitamin C, which enhances iron absorption, unlike the other options.