Nokea
The nurse is assessing the laboring client who is morbidly obese. The nurse is unable to determine the fetal position. Which action should be performed by the nurse to obtain the most accurate method of determining fetal position in this client?
- A. Inspect the client’s abdomen.
- B. Palpate the client’s abdomen.
- C. Perform a vaginal examination.
- D. Perform transabdominal ultrasound.
Correct Answer: D
Rationale: Real-time transabdominal ultrasound (US) is the most accurate assessment measure to determine the fetal position and is frequently available in the birthing setting. US images may be used to assess fetal lie, presentation, and position in the morbidly obese client. Inspection of the abdomen can be used to determine fetal position, but because the client is obese, this is not the most accurate method. Palpation of the abdomen can be used to determine fetal position, but because the client is obese, this is not the most accurate method. Vaginal examination can be used to determine fetal position, but because the client is obese, this is not the most accurate method.
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Twenty-four hours post—vaginal delivery, the postpartum client tells the nurse that she is concerned because she has not had a bowel movement (BM) since before delivery. Which action should be taken by the nurse?
- A. Document the data in the client’s health care records
- B. Notify the health care provider immediately
- C. Administer a laxative that has been prescribed pm
- D. Assess the client’s abdomen and bowel sounds
Correct Answer: A
Rationale: A spontaneous BM may not occur for 2 to 3 days after childbirth due to decreased muscle tone in the intestines during labor and the immediate postpartum period, possible prelabor diarrhea, and decreased food intake and dehydration during labor. Thus, documentation of the lack of a BM is the only action required. There is no need to notify the HCP for a normal finding. A laxative is unnecessary since a BM is not expected for 2 to 3 days postdelivery. Bowel sounds are not altered by a vaginal delivery, even though the passage of stool through the intestines is slowed.
The experienced nurse instructs the new nurse that a vaginal examination should not be performed on the newly admitted client with possible grade 3 abruptio placentae. Which illustration shows the new nurse’s thinking about the uterus of the client with the grade 3 abruptio placentae?
- A. Illustration 1
- B. Illustration 2
- C. Illustration 3
- D. Illustration 4
Correct Answer: D
Rationale: Illustration 4 shows severe grade 3 abruptio placentae. More than 50% of the placenta separates with concealed hemorrhage. Illustration 1 shows complete placenta previa and not abruptio placentae. Illustration 2 shows partial placenta previa and not abruptio placentae. Illustration 3 shows mild grade 1 abruptio placentae. Less than 15% of the placenta separates with concealed hemorrhage.
The pregnant client presents to the ED with a large amount of painless, bright red bleeding. She looks to be about 30 to 34 weeks pregnant based on her uterine size. She speaks limited English and is unable to communicate with the staff. Which actions should the nurse take? Select all that apply.
- A. Call for an interpreter for this client.
- B. Establish an intravenous access.
- C. Auscultate for fetal heart tones.
- D. Place the client into a lithotomy position.
- E. Perform a digital pelvic examination.
Correct Answer: A,B,C
Rationale: The nurse should call for an interpreter so that the client is able to communicate. An IV access should be performed by the nurse to administer any needed medications. Auscultating FHT will provide information about fetal well-being. Positioning the client in a lithotomy position can cause abdominal pain, and there is no indication that birth is imminent. The pregnant client who presents in later pregnancy should never have a digital pelvic examination because this could cause additional bleeding, especially if she has placenta previa.
The laboring multigravida client’s last vaginal examination was 8/90/+1. The client now states feeling rectal pressure. Which action should the nurse perform first?
- A. Encourage the client to push.
- B. Notify the obstetrician or midwife.
- C. Help the client to the bathroom.
- D. Complete another vaginal exam.
Correct Answer: D
Rationale: The nurse should first evaluate labor progress by performing another vaginal exam. Previously the client was almost fully effaced (90%), and fetal station was 1 cm below the ischial spines (+1). Rectal pressure is often due to pressure exerted during descent of the fetal presenting part. The client needs to be fully dilated (10 cm, not 8 cm) and fully effaced (100%, not 90%) before being encouraged to push. Pushing too early may cause cervical edema and lacerations and may slow the labor process. Rectal pressure may indicate that the client has progressed since the last vaginal exam. Another vaginal exam should be performed before contacting the obstetrician or midwife. During labor, rectal pressure is usually not due to the need for a bowel movement because intestinal motility decreases.
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.