Nokea
The nurse is assessing pregnant clients. During which time frames should the nurse expect clients to report frequent urination throughout the night? Select all that apply.
- A. Before the first missed menstrual period
- B. During the first trimester
- C. During the second trimester
- D. During the third trimester
- E. One week following delivery
Correct Answer: B,D
Rationale: Urinary frequency is most likely to occur in the first and third trimesters. First-trimester urinary frequency occurs as the uterus enlarges in the pelvis and begins to put pressure on the bladder. In the third trimester, urinary frequency returns due to the increased size of the fetus and uterus placing pressure on the bladder. Women do not typically experience urinary changes before the first missed menstrual period. During the second trimester, the uterus moves into the abdominal cavity, putting less pressure on the bladder. Nocturnal frequency occurring a week after delivery may be a sign of a UTI.
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The postpartum client is being discharged to home with a streptococcal puerperal infection. The client is taking antibiotics but asks the nurse what precautions she should take at home to prevent spreading the infection to her husband, newborn, and toddler. Which is the best response by the nurse?
- A. “No precautions are necessary since you are taking antibiotics.”
- B. “You should always wear a mask when caring for your newborn and toddler.”
- C. “Wash your hands before caring for your children and after toileting and perineal care.”
- D. “Your husband should provide all cares for both children until your infection is gone.”
Correct Answer: C
Rationale: The course of an endometrial infection is approximately 7 to 10 days, and thus standard precautions should be in place for that period of time even if the client has started antibiotics. Puerperal infections are not spread by droplets, and thus a mask is not necessary. Other than hand hygiene, no additional precautions need to be taken by the client in her home. The client is able to provide cares for her children, but hand washing is required before cares.
The nurse includes which topic in the prenatal education plan for a first-time mother?
- A. Breastfeeding techniques
- B. Advanced labor pain management
- C. Neonatal surgical procedures
- D. Postpartum weight loss strategies
Correct Answer: A
Rationale: Breastfeeding techniques are essential for a first-time mother to ensure successful feeding and bonding with the newborn.
The nurse is caring for the postpartum family. The nurse determines that paternal engrossment is occurring when which observation is made of the newborn’s father?
- A. Talks to his newborn from across the room
- B. Shows similarities between his and the baby’s ears
- C. Expresses feeling frustrated when the infant cries
- D. Seems to be hesitant to touch his newborn
Correct Answer: B
Rationale: Not making face-to-face contact with the infant during communication demonstrates a lack of engrossment. In North American culture, engrossment is demonstrated by the father touching the infant, making eye contact with the infant, and verbalizing awareness of features in the newborn that are similar to his and that validate his claim to that newborn. Feelings of frustration are not uncommon to fathers and are characteristic of the second stage, or reality stage, of the transition to fatherhood but are not a sign of engrossment. A hesitation to touch the infant demonstrates a lack of engrossment.
The primigravida client has been pushing for 2 hours when the infant’s head emerges. The infant fails to deliver, and the obstetrician states that the turtle sign has occurred. Which should be the nurse’s interpretation of this information?
- A. There is cephalopelvic disproportion.
- B. The infant has a shoulder dystocia.
- C. The infant’s position is occiput posterior.
- D. The infant’s umbilical cord is prolapsed.
Correct Answer: B
Rationale: The “turtle sign” occurs when the infant’s head suddenly retracts back against the mother’s perineum after emerging from the vagina, resembling a turtle pulling its head back into its shell. This head retraction is caused by the infant’s anterior shoulder being caught on the back of the maternal pubic bone (shoulder dystocia), preventing delivery of the remainder of the infant. Cephalopelvic disproportion occurs when the head is too large to fit through the client’s pelvis. Fetal descent ceases, and infant’s head would not emerge. Persistent occiput posterior results in prolonged pushing; however, once the head is born, the remainder of the birth occurs without difficulty. A cord prolapse occurs when the umbilical cord enters the cervix before the fetal presenting part and is considered a medical emergency.
The postpartum client delivered a full-term infant 2 days previously. The client states to the nurse, “My breasts seem to be growing, and my bra no longer fits.” Which statement should be the basis for the nurse’s response to the client’s concern?
- A. Rapid enlargement of breasts usually is a symptom of infection.
- B. Increasing breast tissue may be a sign of postpartum fluid retention.
- C. Thrombi may form in veins of the breast and cause increased breast size.
- D. Breast tissue increases in the early postpartum period as milk forms.
Correct Answer: D
Rationale: Infection in the breast tissue results in flulike symptoms and redness and tenderness of the breast. It is usually unilateral and does not cause bilateral breast enlargement. Fluid is not retained during the postpartum period; rather, clients experience diuresis of the excess fluid volume accumulated during pregnancy. Fullness in both breasts would not be the result of thrombi formation. Symptoms of thrombi include redness, pain, and increased skin temperature over the thrombi. Breast tissue increases as breast milk forms, so a bra that was adequate during pregnancy may no longer be adequate by the second or third postpartum day.