Nokea
The nurse is assessing a client in the active stage of labor. Which findings indicate to the nurse that the client is beginning the second stage of labor?
- A. The membranes have ruptured.
- B. The cervix is dilated completely.
- C. The client begins to expel clear vaginal fluid.
- D. The spontaneous urge to push is initiated from perineal pressure.
Correct Answer: B
Rationale: The correct answer is B because complete dilation of the cervix marks the transition from the first to the second stage of labor. This indicates that the client is ready to start pushing the baby out. Choice A is incorrect as ruptured membranes can occur in any stage of labor. Choice C is incorrect as clear vaginal fluid expulsion is not a specific indicator of the second stage. Choice D is incorrect as the urge to push can be experienced in the first stage as well.
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What is the appropriate intervention for a mother with a third-degree perineal tear postpartum?
- A. Apply ice packs to the perineum
- B. Administer stool softeners as prescribed
- C. Encourage the mother to avoid heavy lifting
- D. Provide perineal exercises for faster recovery
Correct Answer: C
Rationale: The correct answer is C: Encourage the mother to avoid heavy lifting. After a third-degree perineal tear, it is crucial to prevent strain on the perineum to promote healing and prevent complications like infection or further tearing. Heavy lifting can increase pressure on the perineum, leading to delayed healing. Ice packs (A) may help reduce swelling initially but do not address the underlying issue. Stool softeners (B) can help prevent constipation and straining during bowel movements but do not directly impact perineal tear healing. Perineal exercises (D) are beneficial for strengthening the pelvic floor muscles in general but should be introduced gradually and not immediately postpartum with a severe tear.
Probable signs of pregnancy
- A. Ballottement (rebounding of the fetus against the examiner's fingers on palpation)
- B. Chadwicks sign (violet coloration of mucous membranes of cervix, vagina, and vulva @4 wks)
- C. Uterine enlargement
- D. Hegar's sign (compressibility and softening of lower uterine segment @6 wks)
Correct Answer: A
Rationale: The correct answer is A: Ballottement. This is a probable sign of pregnancy because it involves the rebounding of the fetus against the examiner's fingers on palpation. This occurs when the examiner pushes against the uterus and feels a bouncing back, indicating the presence of a fetus.
Choice B, Chadwick's sign, is actually the violet coloration of mucous membranes of cervix, vagina, and vulva at around 6-8 weeks, not 4 weeks as stated.
Choice C, uterine enlargement, is a presumptive sign of pregnancy as it can be caused by factors other than pregnancy, such as fibroids.
Choice D, Hegar's sign, involves the compressibility and softening of the lower uterine segment at around 6 weeks, but it is a probable sign rather than a definitive one like Ballottement.
A patient has just been admitted to labor and delivery. She is having mild contractions lasting 30 seconds every 15 minutes. The patient wants to have a mediation free birth. When discussing medication alternatives, the nurse should be sure the patient understands that:
- A. maternal pain and stress can have a more adverse effect on the fetus than a small amount of analgesia
- B. In order to respect her wishes no pain medication will be given
- C. the use of medication allows the patient to rest and be less fatigued
- D. pain relief will allow a more enjoyable birth experience
Correct Answer: A
Rationale: The correct answer is A because maternal pain and stress can lead to increased levels of stress hormones, which can negatively affect the fetus. By providing a small amount of analgesia, the patient can experience relief from pain and stress without compromising the well-being of the fetus.
Option B is incorrect because it disregards the potential benefits of providing some pain relief to the patient while still respecting her desire for a medication-free birth.
Option C is incorrect because while medication may provide some rest and alleviate fatigue, the primary concern in this scenario is the impact on the fetus rather than the patient's comfort.
Option D is incorrect because the main focus should be on ensuring the safety and well-being of both the mother and the fetus, rather than solely on the mother's enjoyment of the birth experience.
Which nursing diagnoses may apply to the childbearing family with special needs? (Select all that apply.)
- A. Risk for spiritual distress
- B. Risk for injury
- C. Readiness for enhanced nutrition
- D. Ineffective breathing pattern
Correct Answer: B
Rationale: The correct answer is B: Risk for injury. This is because families with special needs in childbearing may face unique challenges leading to potential risks of injury, such as physical limitations or difficulties in providing adequate care. Option A is incorrect as spiritual distress is not directly related to physical safety. Option C is incorrect as enhanced nutrition readiness does not directly address safety concerns. Option D is incorrect as ineffective breathing pattern is a specific health issue not necessarily related to the family's safety. Therefore, B is the most appropriate nursing diagnosis for addressing safety concerns in the childbearing family with special needs.
A postpartum client is getting ready to receive a Depo-Provera injection. Which statement by the client indicates that further teaching by the nurse is necessary?
- A. You will give this shot just like the rubella injection I received yesterday.
- B. I will watch my weight and try to exercise daily after receiving this injection.
- C. I will need to reschedule a follow-up appointment in 3 months.
- D. It might take me a year to get pregnant after receiving this type of birth control.
Correct Answer: A
Rationale: The correct answer is A because the client's comparison of receiving a Depo-Provera injection to a rubella injection is incorrect. Depo-Provera is a hormonal contraceptive injection that does not have the same administration process or purpose as a rubella vaccination. This indicates a lack of understanding about the medication.
Choice B is not the correct answer because it shows the client's awareness of the importance of weight management and exercise in conjunction with receiving the injection.
Choice C is not the correct answer because it demonstrates the client's understanding of the need for a follow-up appointment in 3 months which is necessary for monitoring and continuation of the contraceptive method.
Choice D is not the correct answer because it shows the client's understanding of the potential delay in fertility after discontinuing Depo-Provera, which is an important aspect of the contraceptive method that the client should be aware of.