Nokea
The client, whose parity is 1, had a vaginal delivery 6 days ago and arrived home yesterday after treatment for endometritis. The home health nurse visits the client and plans teaching after seeing which most concerning item in the client’s bathroom?
- A. A box of tampons on the floor outside of the shower stall.
- B. Loofa bath sponge sitting on the seat of the shower stall.
- C. Damp towel bunched on the towel bar and near the floor.
- D. Can of bathroom cleaner on the floor of the shower stall.
Correct Answer: A
Rationale: The nurse should plan teaching about the use of tampons during postpartum. The tampon may irritate or dry the vagina, holds lochia in the body, and increases the risk of infection. The client should be instructed to wear a peripad. Loofas or bath sponges for bathing the body postpartum are not contraindicated. While it is a good idea to hang towels neatly so that they dry more rapidly and reduce mold growth, this is not a priority for teaching. The bathroom cleaner would be dangerous to an older child who is more mobile, but the client’s parity is 1. The client would be wise to start considering safety issues by placing this out of reach, but this is not the priority teaching item.
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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.
The nurse is assessing pregnant clients. During which time frames should the nurse expect clients to report frequent urination throughout the night? Select all that apply.
- A. Before the first missed menstrual period
- B. During the first trimester
- C. During the second trimester
- D. During the third trimester
- E. One week following delivery
Correct Answer: B,D
Rationale: Urinary frequency is most likely to occur in the first and third trimesters. First-trimester urinary frequency occurs as the uterus enlarges in the pelvis and begins to put pressure on the bladder. In the third trimester, urinary frequency returns due to the increased size of the fetus and uterus placing pressure on the bladder. Women do not typically experience urinary changes before the first missed menstrual period. During the second trimester, the uterus moves into the abdominal cavity, putting less pressure on the bladder. Nocturnal frequency occurring a week after delivery may be a sign of a UTI.
Before teaching the client about the nutritional needs during pregnancy, which nursing intervention is most appropriate?
- A. Determine if the client needs to gain or lose weight.
- B. Assess the client's current eating pattern and preferences.
- C. Determine if the client knows how to accurately count calories.
- D. Develop a sample menu that includes the required nutrients.
Correct Answer: B
Rationale: Assessing the client's eating patterns and preferences provides a baseline for tailored nutritional education.
The nurse responds that, for clients with uncomplicated pregnancies, it is usually best to plan monthly visits for the first 28 weeks and then more frequent visits following which schedule?
- A. Weekly for the remainder of the pregnancy
- B. Every 2 weeks for the remainder of the pregnancy
- C. Every 2 weeks up to 36 weeks, then weekly for the last month
- D. Weekly up to 36 weeks, then twice weekly for the last month
Correct Answer: C
Rationale: Standard prenatal care involves monthly visits until 28 weeks, biweekly until 36 weeks, and weekly thereafter for uncomplicated pregnancies.
The client has been in labor for 21 hours. Induction was started 16 hours ago, and she is now dilated 5 cm. She has made little progress, and there has been no fetal descent. The HCP identifies cephalopelvic disproportion (CPD). The nurse should prepare the client for which mode of delivery?
- A. Traditional vaginal delivery
- B. Forceps-assisted delivery
- C. Vacuum-assisted delivery
- D. Cesarean section delivery
Correct Answer: D
Rationale: A fetus diagnosed with CPD is unable to be delivered vaginally and requires a cesarean section birth. A vaginal delivery is contraindicated once CPD has been identified due to the risk of fetal and maternal trauma. Forceps delivery is contraindicated once CPD has been identified due to the risk of fetal and maternal trauma. Vacuum delivery is contraindicated once CPD has been identified due to the risk of fetal and maternal trauma.