Nokea
The laboring client tells the nurse that she wants to avoid an episiotomy if possible. Which response by the nurse is best?
- A. “Usually making an episiotomy incision is avoided whenever possible.”
- B. “Having an episiotomy reduces prolonged pushing and perineal trauma.”
- C. “An episiotomy is routine because it can prevent pelvic floor damage.”
- D. “Tell me more about your concerns about having an episiotomy.”
Correct Answer: A
Rationale: This statement is best. An episiotomy may be used in some circumstances but is usually avoided if possible. Use of episiotomy increases (not reduces) perineal trauma and increases healing time. Use of episiotomy is not routine, does not decrease pelvic floor damage, and may increase the severity of the trauma. Having the client tell the nurse more about her concerns regarding episiotomy is unnecessary and avoids responding to the client’s comment.
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When the client asks why folic acid is important, which response by the nurse is most accurate?
- A. Folic acid helps prevent neural tube defects such as spina bifida.
- B. Folic acid helps build strong bones for your baby.
- C. Folic acid helps your baby become resistant to infections.
- D. Folic acid prevents your baby from becoming anemic.
Correct Answer: A
Rationale: Folic acid is critical for preventing neural tube defects like spina bifida by supporting early fetal development.
Which nursing instructions concerning exercise during pregnancy are accurate? Select all that apply.
- A. Avoid exercising during hot, humid weather.
- B. Avoid exercises involving bouncing or jumping movements.
- C. Drink plenty of fluids before and after exercising.
- D. Limit strenuous activity to no more than 60 minutes a session.
- E. Perform exercises only in the supine position.
- F. Limit exercising to once per week.
Correct Answer: A,B,C
Rationale: Exercising in hot weather risks overheating, bouncing movements may strain joints, and hydration is crucial. Supine exercises are avoided late in pregnancy.
The nurse is caring for the client who is being evaluated for a suspected malpresentation. The fetus’s long axis is lying across the maternal abdomen, and the contour of the abdomen is elongated. Which should be the nurse’s documentation of the lie of the fetus?
- A. Vertex
- B. Breech
- C. Transverse
- D. Brow
Correct Answer: C
Rationale: A transverse lie occurs in 1 in 300 births and is marked by the fetus’s lying in a side-lying position across the abdomen. Vertex presentations result in the lie’s being vertical. Breech presentations result in the lie’s being vertical. A brow presentation is also a vertical lie.
The client tells the nurse, “Most days, I am so happy I am pregnant, but other days, I am not sure that I am ready to have a baby.” Which is the most accurate response from the nurse?
- A. “This is such a happy time in your life. You need to be optimistic to feel happy.”
- B. “How does your spouse feel about the pregnancy? I hope he is happy about the baby.”
- C. “Feeling differently from day to day is normal. How do you feel today?”
- D. “Why do you feel this way? Is there something I can do to make it better for you?”
Correct Answer: C
Rationale: It is most therapeutic to acknowledge the client’s feelings and probe for more information on her thoughts and feelings about the pregnancy. Not all clients consider pregnancy a happy time in their lives, and the nurse should never tell the client how to feel. The nurse should not divert the client’s concerns away from self by bringing up the father’s adaptation to the pregnancy, even though paternal adaptation is related to maternal adaptation. The client may not be able to identify why she has the feelings she is experiencing or how the nurse can make her feel better. This response does not provide an avenue for further exploration of the client’s concerns.
While assessing the postpartum client who is 10 hours post—vaginal delivery, the nurse notes a perineal pad that is totally saturated. To determine the significance of this finding, which question should the nurse ask the client first?
- A. “How often are you experiencing uterine cramping?”
- B. “When was the last time you changed your peri-pad?”
- C. “Are you having any bladder urgency or frequency?”
- D. “Did you pass clots that required changing your peri-pad?”
Correct Answer: B
Rationale: Once the nurse has determined the length of time the pad has been in place, the nurse could decide if asking about uterine cramping is appropriate. The amount of lochia on a perineal pad is influenced by the individual client’s pad changing practices. Thus, the nurse should ask about the length of time the current pad has been in place before making a judgment about whether the amount is concerning. Although bladder incontinence could cause pad saturation, it is more important to ask about the length of time the pad has been in place. Based on the client’s answer, the nurse could decide if asking about bladder urgency or frequency needs further assessment. Passing clots may require more frequent pad change, but first the nurse should determine if the reason for the saturated pad is the length of time it has been in place.