Nokea
The nurse is caring for a primipara in active labor when the fetus develops severe bradycardia with late decelerations, and an emergency cesarean delivery is performed with the client under general anesthesia. After the delivery, the client tells the nurse, 'I feel terrible. This is exactly what I didn't want to happen!' Which of the following is a priority nursing diagnosis for this client?
- A. Interrupted family processes related to cesarean delivery.
- B. Anxiety related to incisional scar and neonatal outcome.
- C. Pain related to surgical incision and uterine cramping.
- D. Situational low self-esteem related to inability to deliver vaginally.
Correct Answer: D
Rationale: The client's statement reflects disappointment and possible feelings of failure due to the unplanned cesarean, making situational low self-esteem the priority. Pain, anxiety, and family processes are secondary concerns post-delivery.
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The physician determines that outlet forceps are needed to assist in the delivery of a primigravid client in active labor with a large-for-gestational-size fetus. The nurse reinforces the physician's explanation for using forceps based on the understanding about which of the following concerning the location of the fetus?
- A. Fetal head at the pelvic outlet.
- B. Fetal head at the ischial spines.
- C. Fetal head above the pelvic brim.
- D. Fetal head in the false pelvis.
Correct Answer: A
Rationale: Outlet forceps are used when the fetal head is at the pelvic outlet, visible at the perineum, allowing safe assisted delivery. Higher fetal positions require different interventions.
A 24-year-old client, G 3, P 1, at 32 weeks' gestation, is admitted to the hospital because of vaginal bleeding. After reviewing the client's history, which of the following factors might lead the nurse to suspect abruptio placentae?
- A. Several hypotensive episodes.
- B. Previous low transverse cesarean delivery.
- C. One induced abortion.
- D. History of cocaine use.
Correct Answer: D
Rationale: Cocaine use is a risk factor for abruptio placentae.
A nurse is teaching a client about the withdrawal method of contraception. Which of the following statements by the nurse is accurate?
- A. The withdrawal method is highly effective when performed correctly.
- B. The withdrawal method does not protect against STIs and has a high failure rate.
- C. The withdrawal method requires medical supervision for effectiveness.
- D. The withdrawal method is more effective than condoms.
Correct Answer: B
Rationale: The withdrawal method does not protect against STIs and has a high failure rate due to pre-ejaculate containing sperm and reliance on timing. It does not require medical supervision and is less effective than condoms.
A primigravid client at 38 weeks' gestation is admitted to the labor suite in active labor. The client's physical assessment reveals a chlamydial infection. The nurse explains that if the infection is left untreated, the neonate may develop which of the following?
- A. Conjunctivitis.
- B. Heart disease.
- C. Skin lesions.
- D. Hepatitis.
Correct Answer: A
Rationale: Untreated chlamydia during delivery can cause neonatal conjunctivitis (ophthalmia neonatorum) via transmission through the birth canal. Heart disease, skin lesions, and hepatitis are not associated with chlamydia.
A newborn is diagnosed with fetal alcohol syndrome. The nurse is teaching this mother what to expect when she goes home with her baby. The nurse determines the mother needs further instruction when she says which of the following?
- A. The way my baby's face looks now will stay that way.'
- B. My baby may be irritable as a newborn.'
- C. I may need some help coping with my newborn.'
- D. My baby will be fine soon after we are home.'
Correct Answer: D
Rationale: FAS is a lifelong condition, and the neonate will not be 'fine' soon after going home, indicating a need for further instruction.