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The laboring multigravida client’s last vaginal examination was 8/90/+1. The client now states feeling rectal pressure. Which action should the nurse perform first?
- A. Encourage the client to push.
- B. Notify the obstetrician or midwife.
- C. Help the client to the bathroom.
- D. Complete another vaginal exam.
Correct Answer: D
Rationale: The nurse should first evaluate labor progress by performing another vaginal exam. Previously the client was almost fully effaced (90%), and fetal station was 1 cm below the ischial spines (+1). Rectal pressure is often due to pressure exerted during descent of the fetal presenting part. The client needs to be fully dilated (10 cm, not 8 cm) and fully effaced (100%, not 90%) before being encouraged to push. Pushing too early may cause cervical edema and lacerations and may slow the labor process. Rectal pressure may indicate that the client has progressed since the last vaginal exam. Another vaginal exam should be performed before contacting the obstetrician or midwife. During labor, rectal pressure is usually not due to the need for a bowel movement because intestinal motility decreases.
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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.
On the basis of the health history data, how should the nurse record the client's pregnancy status on the prenatal records?
- A. Multipara
- B. Primipara
- C. Primigravida
- D. Multigravida
Correct Answer: C
Rationale: A primigravida is a woman pregnant for the first time, which matches the client's status of being possibly 2 months pregnant with no prior pregnancies.
The client, who is Chinese American and pregnant, is receiving nutritional counseling about the need for increased amounts of calcium in her diet. Which response by the nurse is most helpful when the client states she does not consume any dairy products?
- A. “Tell me how you perceive dairy products in your culture.”
- B. “Try having a glass of soy milk at each meal and at bedtime.”
- C. “Tell me about your intake of fortified tofu and leafy green vegetables.”
- D. “Rice milk fortified with calcium and nettle tea are good calcium choices.”
Correct Answer: C
Rationale: Assessing the client’s intake of calcium-rich foods is the best response. Both fortified tofu and leafy green vegetables are high in calcium and are common foods consumed in the Chinese American diet. Although asking about the client’s perception of dairy products shows cultural sensitivity, the client has already stated she does not consume these. This statement is not the most helpful regarding helping the client to increase calcium intake in her diet. The nurse is making a recommendation without further assessing the client’s dietary preferences. Soy milk should be calcium fortified; yet, according to research the calcium content can be as much as 85 percent less than the amount indicated on the product label. Both rice milk fortified with calcium and nettle tea are sources of calcium; however, the nurse is making an assumption that the client consumes these beverages.
The nurse educates the breastfeeding client diagnosed with mastitis. The nurse evaluates that the client has an adequate understanding of how to prevent mastitis in the future when the client makes which statements? Select all that apply.
- A. “Incorrect latch of my baby can lead to mastitis.”
- B. “I should perform hand hygiene before I breastfeed.”
- C. “I should rinse my baby’s mouth before I let her latch.”
- D. “A tight underwire bra has support that prevents mastitis.”
- E. “I should allow my nipples to air-dry after breastfeeding.”
Correct Answer: A,B,E
Rationale: Incorrect latch can cause nipple tissue to blister, crack, and bleed. These breaks in the tissue may serve as an entry point for pathogens. Hand hygiene prior to breastfeeding reduces the number of pathogens available for invasion. While the infant’s nose and throat are sources of pathogenic organisms that might cause mastitis, washing the infant’s mouth would be difficult and would not provide adequate protection for the mother. Wearing a tight bra, especially with an underwire, may restrict milk ducts, providing milk stasis and a medium for pathogenic growth. Allowing breasts to air-dry helps to reduce skin breakdown that might be caused by a moist, wet environment.
Twenty-four hours post—vaginal delivery, the postpartum client tells the nurse that she is concerned because she has not had a bowel movement (BM) since before delivery. Which action should be taken by the nurse?
- A. Document the data in the client’s health care records
- B. Notify the health care provider immediately
- C. Administer a laxative that has been prescribed pm
- D. Assess the client’s abdomen and bowel sounds
Correct Answer: A
Rationale: A spontaneous BM may not occur for 2 to 3 days after childbirth due to decreased muscle tone in the intestines during labor and the immediate postpartum period, possible prelabor diarrhea, and decreased food intake and dehydration during labor. Thus, documentation of the lack of a BM is the only action required. There is no need to notify the HCP for a normal finding. A laxative is unnecessary since a BM is not expected for 2 to 3 days postdelivery. Bowel sounds are not altered by a vaginal delivery, even though the passage of stool through the intestines is slowed.