Nokea
The labor and delivery nurse is assigned to triage for the day. There are four clients already in rooms and the following reports have been received about each of these clients. To provide the safest care and best manage time, the nurse should plan to see which client first?
- A. A primipara in active labor at 5 cm asking to be admitted and wanting an epidural.
- B. A primipara who is 100% effaced, 8 cm dilated, and ready to push.
- C. A multipara who thinks her water broke 2 hours ago.
- D. A multipara with contractions every 5 minutes who is 3 cm dilated.
Correct Answer: B
Rationale: A primipara at 8 cm, 100% effaced, and ready to push is in the second stage of labor, requiring immediate attention to prepare for delivery. Other clients are in earlier stages or need assessment but are less urgent.
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A client is considering the contraceptive implant. Which of the following side effects should the nurse discuss?
- A. Guaranteed weight loss.
- B. Irregular bleeding and headaches.
- C. Permanent infertility.
- D. Increased risk of ovarian cancer.
Correct Answer: B
Rationale: The contraceptive implant may cause irregular bleeding and headaches, especially initially. It does not guarantee weight loss, cause permanent infertility, or increase ovarian cancer risk.
A multigravid client thought to be at 14 weeks' gestation reports that she is experiencing such severe morning sickness that "she has not been able to keep anything down for a week." The nurse should assess for signs and symptoms of which of the following?
- A. Hypercalcemia.
- B. Hypobilirubinemia.
- C. Hypokalemia.
- D. Hyperglycemia.
Correct Answer: C
Rationale: Persistent vomiting can lead to hypokalemia.
A nurse is counseling a client about the use of spermicides. Which of the following instructions should the nurse include?
- A. Apply spermicide 10-30 minutes before intercourse.
- B. Use spermicide alone for maximum effectiveness.
- C. Leave spermicide in place for at least 24 hours.
- D. Apply spermicide after intercourse.
Correct Answer: A
Rationale: Spermicide should be applied 10-30 minutes before intercourse for optimal effectiveness. It is not most effective alone, should not be left for 24 hours, and is applied before, not after, intercourse.
The cervix of a 15-year-old primigravid client admitted to the labor area is 2 cm dilated and 50% effaced. Her membranes are intact, and contractions are occurring every 5 to 6 minutes. Which of the following should the nurse recommend at this time?
- A. Resting in the right lateral recumbent position.
- B. Using in the left lateral recumbent position.
- C. Walking around in the hallway.
- D. Sitting in a comfortable chair for a period of time.
Correct Answer: C
Rationale: In early labor (2 cm dilation), ambulation (walking) promotes labor progression by using gravity to encourage fetal descent and enhance contractions. Lateral positions are better for rest or later stages, and sitting may not aid progression as effectively.
In preparation for discharge, the nurse discusses sexual issues with a primiparous client who had a routine vaginal delivery with a midline episiotomy. The nurse should instruct the client that she can resume sexual intercourse:
- A. In 6 weeks when the episiotomy is completely healed.
- B. After a postpartum check by the health care provider.
- C. Whenever the client is feeling amorous and desirable.
- D. When lochia flow and episiotomy pain have stopped.
Correct Answer: D
Rationale: Resuming sexual intercourse is safe when lochia has stopped and episiotomy pain has resolved, indicating healing.