Nokea
The nurse is assessing the Hispanic client who is in the active stage of labor. Which is the most crucial information that the nurse should assess related to the client’s ethnicity and stage of labor?
- A. Choice of pain control measures
- B. Desire for hot or cold fluids
- C. Persons to be in the room during labor and birth
- D. Desire for circumcision if a male infant is born
Correct Answer: A
Rationale: Because cultural variations exist in pain control measures used and pain tolerance, the most crucial assessment in the active stage of labor is the client’s choice of pain control measures. A desire for hot or cold fluids is an important aspect that should be determined during the early stage of labor. Determination of support persons is an important aspect that should be made during the early stage of labor. The desire for circumcision is an important consideration, but it is not the primary need during the active stage of labor.
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After gathering further information about the edema, the nurse advises the client to limit the intake of which substance?
- A. Sodium
- B. Potassium
- C. Vitamin C
- D. Magnesium
Correct Answer: A
Rationale: Limiting sodium intake helps reduce fluid retention, which contributes to edema in pregnancy.
The nurse teaches the client to monitor which newborn condition?
- A. Umbilical cord stump for infection
- B. Daily weight gain over 1 pound
- C. Frequent crying as abnormal
- D. No bowel movements for a week
Correct Answer: A
Rationale: Monitoring the umbilical cord stump for infection (redness, discharge) is critical for newborn health.
The laboring client tells the nurse that she wants to avoid an episiotomy if possible. Which response by the nurse is best?
- A. “Usually making an episiotomy incision is avoided whenever possible.”
- B. “Having an episiotomy reduces prolonged pushing and perineal trauma.”
- C. “An episiotomy is routine because it can prevent pelvic floor damage.”
- D. “Tell me more about your concerns about having an episiotomy.”
Correct Answer: A
Rationale: This statement is best. An episiotomy may be used in some circumstances but is usually avoided if possible. Use of episiotomy increases (not reduces) perineal trauma and increases healing time. Use of episiotomy is not routine, does not decrease pelvic floor damage, and may increase the severity of the trauma. Having the client tell the nurse more about her concerns regarding episiotomy is unnecessary and avoids responding to the client’s comment.
Which method best promotes client comfort during the pelvic examination?
- A. Have the client lift her head off the table.
- B. Have the client press her back into the examination table.
- C. Have the client tighten her buttocks.
- D. Tell the client to let her knees fall outward.
Correct Answer: D
Rationale: Letting the knees fall outward relaxes the pelvic muscles, reducing discomfort during the pelvic examination.
When one participant asks the nurse what can be done to relieve leg cramps while working, which instruction by the nurse is correct?
- A. Increase protein intake to five to six servings per day.
- B. Wear elastic stockings when at work.
- C. Point the toes frequently toward the head.
- D. Massage the leg when a cramp occurs.
Correct Answer: C
Rationale: Pointing toes toward the head (dorsiflexion) relieves leg cramps by stretching the calf muscles, unlike the other options.