Nokea
The nurse is caring for a postpartum client with a perineal laceration. What comfort measure is most appropriate?
- A. Encourage warm sitz baths.
- B. Apply warm compresses to the perineum.
- C. Provide a heating pad for the lower abdomen.
- D. Offer an ice pack for the perineum.
Correct Answer: D
Rationale: Ice packs help reduce swelling and discomfort in the perineal area during the initial postpartum period.
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The nurse is monitoring a client in active labor. What finding indicates the need for immediate intervention?
- A. Contractions every 2–3 minutes.
- B. Fetal heart rate of 90 beats/minute.
- C. Cervical dilation of 6 cm.
- D. Client reports back pain.
Correct Answer: B
Rationale: A fetal heart rate of 90 beats/minute is bradycardia, indicating potential fetal distress.
What factor is known to increase the risk of gestational DM?
- A. Weigh 100kg prior to pregnancy
- B. Previous birth AGA
- C. Maternal age younger than 25
- D. Previous diagnosis of type 2 diabetes
Correct Answer: D
Rationale: A previous diagnosis of type 2 diabetes is a known risk factor for developing gestational diabetes mellitus (GDM). Women who have had diabetes prior to pregnancy are more likely to develop GDM due to pre-existing insulin resistance. This increased risk is why healthcare providers closely monitor pregnant women with a history of type 2 diabetes. It is important for these women to manage their blood sugar levels carefully during pregnancy to reduce the risk of complications for both the mother and the baby.
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.
How should a nurse assess for proper latch during breastfeeding?
- A. Ensure the baby's nose is covered during feeding
- B. Ensure the baby's lips are sealed around the areola
- C. Check for audible swallowing during feeding
- D. Encourage frequent feeding attempts
Correct Answer: B
Rationale: Ensuring the baby's lips are sealed around the areola promotes effective milk transfer and reduces pain.
What is an advantage of the cervical cap over the diaphragm?
- A. a lower failure rate
- B. its ease of insertion
- C. that it can remain in place for 48 hours
- D. that spermicide is not needed
Correct Answer: A
Rationale: The advantage of the cervical cap over the diaphragm is that it typically has a lower failure rate in preventing pregnancy. Failure rates for contraceptive methods refer to the percentage of women who become pregnant within the first year of typical use. The cervical cap is generally associated with a lower failure rate compared to the diaphragm due to its snugger fit and ability to cover the cervix more effectively, resulting in better protection against sperm entering the uterus. This makes the cervical cap a more reliable option for women seeking effective contraception.