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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A primiparous client has just delivered a healthy male infant. The client and her husband are Muslim and the husband begins chanting a song in Arabic while holding the neonate. The nurse interprets the father's actions as indicative of which of the following?
- A. Thanking Allah for giving him a male heir.
- B. Singing to his son from the Koran in praise of Allah.
- C. Expressing appreciation that his wife and son are healthy.
- D. Performing a ritual similar to baptism in other religions.
Correct Answer: D
Rationale: The chanting is likely the Adhan, a Muslim ritual where the call to prayer is recited to the newborn, similar to a baptismal rite.
Which of the following would the nurse include in the teaching plan for a 16-year-old primigravid client in early labor concerning active relaxation techniques to help her cope with pain?
- A. Relaxing uninvolved body muscles during uterine contractions.
- B. Practicing being in a deep, meditative, sleeplike state.
- C. Focusing on an object in the room during the contractions.
- D. Breathing rapidly and deeply between contractions.
Correct Answer: A
Rationale: Active relaxation involves consciously relaxing uninvolved muscles (e.g., face, arms) during contractions to conserve energy and reduce tension, aiding pain management. Meditation is less practical during active labor, focusing on an object is a distraction technique, and rapid breathing between contractions may cause hyperventilation.
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.
A nurse is counseling a client about the contraceptive sponge. Which of the following instructions should the nurse include?
- A. Insert the sponge at least 1 hour before intercourse.
- B. Leave the sponge in place for at least 6 hours after intercourse.
- C. Reuse the sponge if it is undamaged.
- D. Apply spermicide to the sponge after insertion.
Correct Answer: B
Rationale: The contraceptive sponge should be left in place for at least 6 hours after intercourse to ensure effectiveness. It should be inserted just before intercourse, cannot be reused, and contains spermicide, so additional application is not needed.
Which of the following instructions about activities during menstruation would the nurse include when counseling an adolescent who has just begun to menstruate?
- A. Take a mild analgesic if needed for menstrual pain.
- B. Avoid cold foods if menstrual pain persists.
- C. Stop exercise while menstruating.
- D. Avoid sexual intercourse while menstruating.
Correct Answer: A
Rationale: Mild analgesics like ibuprofen can effectively manage menstrual pain. There is no evidence supporting avoiding cold foods, and moderate exercise can alleviate cramps. Sexual intercourse during menstruation is a personal choice and not medically contraindicated.