Nokea
The nurse examines a client who is admitted in active labor and determines the cervix is 3 cm dilated 50% effaced, and the presenting part is at 0 station. An hour later. she tells the nurse that she wants to go to the bathroom. Which action should the nurse implement first?
- A. Review the fetal heart rate pattern
- B. Check the pH of the vaginal fluid
- C. Determine cervical dilation.
- D. Palpate the client's bladder
Correct Answer: D
Rationale: A desire to use the bathroom may indicate a full bladder, which can impede labor progress. Palpating the bladder is the priority to assess this.
You may also like to solve these questions
The nurse is caring for a client who delivered 6 hours ago. Assessment findings reveal a boggy uterus that is displaced above and to the right of the umbilicus. Which action should the nurse take?
- A. Encourage voiding
- B. Notify healthcare provider
- C. Inspect the perineal pad
- D. Monitor vital signs
Correct Answer: A
Rationale: A boggy uterus displaced above and to the right of the umbilicus often indicates a distended bladder, which can prevent proper uterine contraction. Encouraging voiding addresses this issue, helping the uterus return to its normal position and firm up.
A nurse is speaking with a client who is addicted to heroin and who just learned that she is pregnant. The client states, 'I just started taking methadone. Is there anything else I can do to make sure my baby is healthy?' Which information should the nurse provide?
- A. Describe genetic testing protocols
- B. Discontinue the methadone right away
- C. Sign up for group therapy sessions
- D. Start a prenatal care plan as soon as possible
Correct Answer: D
Rationale: Early prenatal care is critical for monitoring maternal and fetal health, managing opioid addiction with methadone under medical supervision, and addressing potential complications.
A client at 18-weeks gestation was informed this morning that she has an elevated alpha-fetoprotein (AFP) level. After the healthcare provider leaves the room, the client asks what she should do next. What information should the nurse provide?
- A. Discuss options for intrauterine surgical correction of congenital defects.
- B. Inform her that a repeat alpha-fetoprotein (AFP) should be evaluated.
- C. Reassure the client that the AFP results are likely to be a false reading.
- D. Explain that a sonogram should be scheduled for definitive results
Correct Answer: D
Rationale: An elevated AFP level is a screening indicator, not a diagnosis. A sonogram is the next step to assess for neural tube defects or other anomalies, providing definitive information.
A new mother who is breastfeeding her 4-week-old infant and has type 1 diabetes, reports that her insulin needs have decreased since the birth of her child. Which action should the nurse implement?
- A. Schedule an appointment for the client with the diabetic nurse educator.
- B. Counsel her to increase her caloric intake
- C. Inform her that a decreased need for insulin occurs while breastfeeding
- D. Advise the client to breastfeed more frequently
Correct Answer: C
Rationale: Breastfeeding can lower insulin requirements due to increased energy expenditure, and informing the client of this normal change is appropriate.
A 25-year-old client who had a severe postpartum hemorrhage following the vaginal birth of twins is transferred to the postpartum unit. The nurse knows that assessment for what complication has the highest priority for this client?
- A. Placenta accreta
- B. Hard, painful uterine afterpains.
- C. Postpartum psychosis.
- D. Disseminated intravascular coagulation
Correct Answer: D
Rationale: Severe postpartum hemorrhage increases the risk of disseminated intravascular coagulation (DIC), a life-threatening condition requiring urgent assessment.