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The nurse is caring for a client in labor who reports intense pressure and the urge to push. What is the priority nursing action?
- A. Perform a sterile vaginal examination.
- B. Instruct the client to breathe through the urge to push.
- C. Notify the healthcare provider.
- D. Increase the oxytocin infusion rate.
Correct Answer: A
Rationale: A vaginal examination is needed to confirm full cervical dilation and readiness for delivery.
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A nurse on a labor and delivery unit is providing teaching to a client who plans to use hypnosis to control labor pain. Which of the following information should the nurse include?
- A. Focusing on controlling body functions
- B. "Synchronized breathing will be required during hypnosis"
- C. "Hypnosis can be beneficial in you practiced it during the prenatal period"
- D. "Hypnosis does not work for controlling pain associated with labor".
Correct Answer: C
Rationale: The correct information that the nurse should include is that "Hypnosis can be beneficial if you practiced it during the prenatal period." This statement is true because hypnosis is a tool that can help individuals manage pain and stress through focused attention and suggestion. By practicing hypnosis techniques during the prenatal period, the individual can become more familiar and comfortable with the practice, making it more effective during labor. It is important to establish a routine and practice hypnosis consistently to maximize its benefits during labor.
During a trauma-informed gynecologic examination, what principle emphasizes the importance of involving the patient in decision making about their health care?
- A. respecting autonomy and empowerment
- B. trauma-sensitive language and communication
- C. providing information and explanation
- D. avoiding triggering situations
Correct Answer: A
Rationale:
A client in the first trimester reports nausea. What dietary recommendation should the nurse make?
- A. Eat dry crackers before getting out of bed.
- B. Avoid eating throughout the day.
- C. Increase intake of spicy foods.
- D. Consume large, infrequent meals.
Correct Answer: A
Rationale: Dry crackers before rising can help manage nausea by stabilizing blood sugar and reducing gastric discomfort.
A nurse is providing teaching to a group of women about risk factors for ovarian cancer. Which of the following should the nurse include? (Select all that apply.)
- A. Nulliparity
- B. History of breastfeeding (???)
- C. Previous use of oral contraceptives
- D. History of breast cancer
Correct Answer: A
Rationale: A. Nulliparity: Women who have never been pregnant (nulliparity) are at an increased risk for ovarian cancer compared to women who have had full-term pregnancies. This is thought to be due to the protective effect of pregnancy and childbirth on the ovaries.
A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time?
- A. Palpate the client's uterine fundus.
- B. Assist the client on a bedpan to urinate.
- C. Prepare to administer oxytocic medication.
- D. Increase the client's fluid intake.
Correct Answer: A
Rationale: The priority nursing intervention in this situation is to palpate the client's uterine fundus. Saturating two perineal pads with blood in a 30-minute period after childbirth is indicative of excessive postpartum bleeding, also known as postpartum hemorrhage (PPH). Palpating the uterine fundus helps the nurse assess for uterine atony, a common cause of PPH. If the fundus is boggy or not firm, it indicates that the uterus is not contracting effectively to control bleeding, which can lead to further complications if not addressed promptly. Once uterine atony is identified, other interventions such as administering oxytocic medications can be initiated to help the uterus contract and control bleeding.