Nokea
The client who is 32 weeks pregnant asks how the nurse will monitor the baby’s growth and determine if the baby is “really okay.” Which assessments should the nurse identify for evaluating the fetus for adequate growth and viability? Select all that apply.
- A. Auscultate maternal heart tones.
- B. Measure the height of the fundus.
- C. Measure the client’s abdominal girth.
- D. Complete a third-trimester ultrasound.
- E. Auscultate the fetal heart tones (FHT).
Correct Answer: B,E
Rationale: Adequate fetal growth is evaluated by measuring the fundal height. Auscultating the FHT assesses fetal viability. The presence of fetal (not maternal) heart tones starting at around 10-12 weeks is a standard to assess fetal growth and viability. The abdominal circumference does not provide information about fetal growth. The increase in abdominal girth could be due to weight gain or fluid retention, not just growth of the baby. Third-trimester ultrasound is neither routine nor advised for routine prenatal care because of the added cost and potential risk to the fetus.
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Which sign of labor should the nurse teach the client to report immediately?
- A. Mild, irregular contractions
- B. Increased fetal movement
- C. Rupture of membranes
- D. Occasional backache
Correct Answer: C
Rationale: Rupture of membranes (water breaking) requires immediate reporting, as it may indicate the onset of labor or risk of infection.
Which statement made by a participant regarding remedies of heartburn and nausea indicates that teaching has been effective?
- A. I should eat frequent, small meals.
- B. I should take an antacid after eating.
- C. I should eat my largest meal in the evening.
- D. I should drink extra water with my meals.
Correct Answer: A
Rationale: Frequent, small meals reduce stomach acid and nausea, unlike large meals or extra water, which may worsen symptoms.
The client had a D&C for treating an incomplete spontaneous abortion. Which statements should the nurse include when preparing the client for discharge the same day? Select all that apply.
- A. “Return for a blood transfusion if bleeding continues to be dark red.”
- B. “Intravenous antibiotics will be prescribed every 8 hours for two days.”
- C. “I can make a referral to a pregnancy loss support group if you like.”
- D. “You need to use contraceptives to avoid getting pregnant for one year.”
- E. “Someone should remain with you at home for the first 12 to 24 hours.”
Correct Answer: C,E
Rationale: The client who had an incomplete spontaneous abortion may experience grief and loss. The nurse should offer to do a referral to a pregnancy loss support group to provide ongoing support after hospital discharge. A D&C is usually performed on an outpatient basis if there are no complications, and the client can return home a few hours after the procedure. Someone should remain with the client to ensure that she is safe and no complications develop. Dark red blood does not necessarily indicate the need for a blood transfusion; it could be old blood. The client should notify the HCP if experiencing heavy bleeding following the D&C. A D&C for treating incomplete spontaneous abortion does not require the routine administration of IV antibiotics. There is no medical need for the client who had a spontaneous abortion to avoid pregnancy for one year.
The nurse is teaching the Muslim client how to correctly latch her baby to her breast for breastfeeding. Two student nurses are observing the instruction. Later, the client requests that the nurse not be allowed to provide her postpartum care. What most likely caused the client to be uncomfortable with the nurse?
- A. Muslim women do not want to breastfeed while in the hospital.
- B. Muslim women wait for their milk to come in before they breastfeed.
- C. Muslim women are uncomfortable breastfeeding in public situations.
- D. Muslim women only breastfeed after the infant is given boiled water.
Correct Answer: C
Rationale: Korean mothers resist breastfeeding in the hospital. Some Asian women believe colostrum is “bad,” and therefore they do not feed until actual breast milk is present. Most Muslim women breastfeed because the Koran encourages it; however, they are uncomfortable about breastfeeding in public situations and prefer privacy. Having two students observing the feeding process most likely would make the client uncomfortable, as she would desire more privacy. Some Asian cultures believe the newborn must be given boiled water until the milk is actually present.
The client, who had a vaginal delivery 18 hours ago, asks the nurse how she should take care of her perineal laceration. Which statements by the nurse are appropriate? Select all that apply.
- A. “You should change your peripad at least twice each day.”
- B. “Once home, use a warm sitz bath to sooth your perineum.”
- C. “Keep your perineum warm and dry until stitches are removed.”
- D. “Use your peri-bottle to apply water to the perineum after each void.”
- E. “Wash your perineum with mild soap at least once each 24 hours.”
- F. “Check your perineum for foul odor or increased redness, heat, or pain.”
Correct Answer: B,D,E,F
Rationale: The peripad should be changed more frequently to reduce the risk of infection. Lochia amount should never exceed a moderate amount (less than a 6-inch stain on a perineal pad). A warm sitz bath is used after the first 24 hours to provide comfort, increase circulation to the area, and reduce the incidence of infection. Perineal lacerations are repaired with sutures that dissolve. Clients do not need to have perineal sutures removed. Cleansing the perineum after each void with the peri-bottle of water provides comfort and helps reduce the chance of infection. Washing with mild soap and rinsing with water each 24 hours reduces the risk of infection. Teaching the client to watch for signs and symptoms of infection is important and allows the client to be an active participant in her care.