Nokea
The nurse is caring for a multigravid client who speaks little English. As the nurse enters the client's room, the nurse observes the client panting on the bed and the fetal head crowning. After calling for assistance and helping the client lie down, which of the following actions should the nurse do next?
- A. Tell the client to push between contractions.
- B. Provide gentle support to the fetal head.
- C. Apply gentle upward traction on the neonate's anterior shoulder.
- D. Massage the perineum to stretch the perineal tissues.
Correct Answer: B
Rationale: With the fetal head crowning, providing gentle support prevents rapid expulsion and perineal trauma. Pushing between contractions is incorrect, traction is for shoulder dystocia, and perineal massage is less urgent.
You may also like to solve these questions
A primigravid client is admitted as an outpatient for an external cephalic version. The nurse should assess the client for which of the following contraindications for the procedure?
- A. Multiple gestation.
- B. Breech presentation.
- C. Maternal Rh-negative blood type.
- D. History of gestational diabetes.
Correct Answer: A
Rationale: External cephalic version (ECV) is contraindicated in multiple gestation due to the risk of cord entanglement or placental issues. Breech presentation is an indication for ECV, not a contraindication. Rh-negative blood type and gestational diabetes do not preclude ECV.
A client is considering the fertility awareness method. Which of the following client statements indicates understanding?
- A. I will track my basal body temperature daily.
- B. I can use this method with irregular cycles.
- C. I will monitor ovulation with a pregnancy test.
- D. I will avoid intercourse throughout the cycle.
Correct Answer: A
Rationale: Tracking basal body temperature daily is a key component of the fertility awareness method. It is less reliable with irregular cycles, pregnancy tests do not monitor ovulation, and intercourse is avoided only during fertile periods.
A nurse is teaching a client about the use of spermicides. Which of the following instructions should the nurse include?
- A. Spermicides must be applied at least 1 hour before intercourse.
- B. Spermicides are most effective when used alone.
- C. Spermicides should be used with barrier methods for increased effectiveness.
- D. Spermicides provide long-term contraception for up to 24 hours.
Correct Answer: C
Rationale: Spermicides are most effective when used with barrier methods like condoms or diaphragms, as they increase efficacy. They should be applied 10-30 minutes before intercourse, are less effective alone, and are effective for about 1 hour, not 24 hours.
A multiparous client delivers dizygotic twins at 37 weeks' gestation. The twin neonates require additional hospitalization after the client is discharged. In planning the family's care, an appropriate goal for the nurse to formulate is that, while the twins are hospitalized, the parents will do which of the following?
- A. Discuss how they will cope with twin infants at home.
- B. Participate in care of the twins as much as possible.
- C. Take turns providing 24-hour observation of the twins.
- D. Identify complications that may occur as the twins develop.
Correct Answer: B
Rationale: Parental participation in twin care during hospitalization promotes bonding, confidence, and skill development. Discussing coping, 24-hour observation, or identifying complications are less immediate or unrealistic.
A client has obtained Plan B (levonorgestrel 0.75 mg, 2 tablets) as emergency contraception. After unprotected intercourse, the client calls the clinic to ask questions about taking the contraceptives. The nurse realizes the client needs further explanation when she makes which of the following responses?
- A. I can wait 3 to 4 days after intercourse to start taking these to prevent pregnancy.
- B. My boyfriend can buy Plan B from the pharmacy if he is over 18 years old.
- C. The birth control works by preventing ovulation or fertilization of the egg.
- D. I can be discussed and have breast tenderness or a headache after using the contraceptive.
Correct Answer: A
Rationale: Plan B is most effective when taken within 72 hours of unprotected intercourse, ideally as soon as possible. Waiting 3 to 4 days reduces its efficacy, indicating a need for further explanation.