Nokea
The nurse emphasizes which safety measure during prenatal education?
- A. Avoiding raw or undercooked meat
- B. Sleeping on the stomach throughout pregnancy
- C. Using saunas regularly
- D. Taking herbal supplements without consultation
Correct Answer: A
Rationale: Avoiding raw or undercooked meat prevents infections like toxoplasmosis, a key safety measure for fetal health.
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The nurse, admitting a 40-week primigravida to the labor unit, just documented the results of a recent vaginal exam: 3/100/—2, RSP. How should the oncoming shift nurse interpret this documentation?
- A. The fetus is approximately 2 cm below maternal ischial spines.
- B. The cervix is totally dilated and effaced, with fetal engagement.
- C. The fetus is breech and posterior to the client’s pelvis.
- D. The fetal lie is transverse, and the fetal attitude is flexion.
Correct Answer: C
Rationale: The nurse should interpret 3/100/—2, RSP as the cervix is 3 cm dilated, 100% effaced, and the fetus is 2 cm above the maternal ischial spines. RSP means that the fetus is to the right of the mother’s pelvis (R), with the sacrum as the specific presenting part (S), which is a breech position. This fetus is also posterior (P). At —2, the fetus is 2 cm above, not below, the maternal ischial spines. Two centimeters below the ischial spines would be recorded as +2. The cervix is 3 cm, not totally dilated. Total dilation would be documented as 10 for the first number. Also, the cervix is 100% effaced, which is total effacement (shortening and thinning out). Fetal lie (relationship of long axis or spine of fetus to long axis of mother) is longitudinal, not transverse. The documentation does not specify if the fetal attitude is flexion.
The nurse recommends which supplement for a vegetarian pregnant client?
- A. Vitamin B12
- B. Vitamin C
- C. Calcium
- D. Magnesium
Correct Answer: A
Rationale: Vitamin B12 supplementation is crucial for vegetarian pregnant clients, as it is primarily found in animal products and supports fetal neurological development.
The nurse is assessing the postpartum client, who is 5 hours postdelivery. Initially, the nurse is unable to palpate the client’s uterine fundus. Prioritize the nurse’s actions to locate the client’s fundus by placing each step in the correct sequence.
- A. Place the side of one hand just above the client’s symphysis pubis.
- B. Press deeply into the abdomen.
- C. Place the other hand at the level of the umbilicus.
- D. Massage the abdomen in a circular motion.
- E. Position the client in the supine position.
- F. If the fundus is not felt, move the upper hand lower on the abdomen and repeat the massage.
Correct Answer: E,A,C,B,D,F
Rationale: Position the client in supine so the height of the uterus is not influenced by an elevated position. Place the side of one hand just above the client’s symphysis pubis. This supports the lower uterine segment and prevents the inadvertent inversion of the uterus during palpation. Place the other hand at the level of the umbilicus. This is the expected location of the uterine fundus on the day of delivery. Press deeply into the abdomen to allow the massage to reach the fundus. Massage the abdomen in a circular motion. This massage should stimulate the uterus to contract and allow location of the fundus to be determined. If the fundus is not felt, move the upper hand lower on the abdomen and repeat the massage. Involution could potentially be occurring more rapidly than expected if the client is breastfeeding and/or had an uncomplicated labor and birth.
Two days after hospital discharge, the nurse is assessing the mother and her newborn twins in their home. Which statement or question made by the nurse best demonstrates empathy?
- A. “You may be feeling overwhelmed. This is normal.”
- B. “I can’t imagine how tired you must be with twins.”
- C. “How are you feeling about being the mother of twins?”
- D. “I saw that laundry is piling up. Do you want a home aide?”
Correct Answer: C
Rationale: Projecting feelings onto the client does not demonstrate empathy. This statement imposes a personal assumption and does not demonstrate empathy. This question demonstrates empathy. The nurse is asking a question to allow the client to explain her situation and feelings while the nurse listens. The nurse is attempting to understand the experience as lived by the client. Acknowledging that laundry is piling up and offering home aide services do not demonstrate empathy. Commenting on the laundry on the first visit may suggest to the client that she lacks support, and she may be defensive or hurt by the acknowledgement.
Which response by the nurse is most relevant when another participant talks about having recurrent mood swings?
- A. Try to avoid fatigue and decrease your stress.
- B. You need to be assessed for a possible mood disorder.
- C. Mood swings are caused by increased blood volume.
- D. Are you ambivalent about the pregnancy?
Correct Answer: A
Rationale: Avoiding fatigue and stress helps manage mood swings, which are common due to hormonal changes in pregnancy.