Nokea
The nurse is caring for the client in labor. Which assessment finding would help the nurse determine whether the client is in the third stage of labor?
- A. Lengthening of fetal cord
- B. Increased bloody show
- C. A strong urge to push
- D. More frequent contractions
Correct Answer: A
Rationale: The third stage of labor lasts from the birth of the baby until the placenta is expelled. Lengthening of the fetal cord is one of several signs indicating placental separation. Bloody show is pink and mucoid in nature and occurs during the first and second stages of labor. During the third stage, there may be increased vaginal bleeding that is bright or dark red. A strong urge to push may occur during the first and second stages of labor. More frequent contractions occur during the first and second stages of labor.
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The client at 31 weeks’ gestation is diagnosed with mild preeclampsia and placed on home management. What information should the nurse include when providing home management instructions? Select all that apply.
- A. “Plan for hospitalization when nearing 36 weeks’ gestation.”
- B. “Weigh daily and inform the HCP of a sudden increase in weight.”
- C. “Home care will be consulted to take your blood pressure (BP) daily.”
- D. “Perform stretching and range-of-motion exercises twice daily.”
- E. “Rest as much as possible, especially in the lateral recumbent position.”
Correct Answer: B,D,E
Rationale: A sudden weight gain could indicate that the mild preeclampsia is uncontrolled and the client is retaining fluid. The HCP should be consulted. Stretching and ROM exercises can help prevent thrombophlebitis and venous stasis. The lateral recumbent position improves uteroplacental blood flow, reduces maternal BP, and promotes diuresis. A diagnosis of mild preeclampsia does not require hospitalization during the antepartum period unless home management fails to reduce the client’s BP, or other complications occur. BP monitoring every 4 to 6 hours is recommended for the client with mild preeclampsia, but the BP can be taken by the client and does not require a consult with home care.
Twenty-four hours after the birth of her first child, the 25-year-old single client tells the nurse that she has several different male sex partners and asks the nurse to recommend an appropriate birth control method for her. Considering her lifestyle, which method of birth control should the nurse suggest?
- A. An intrauterine device (IUD)
- B. Depot-medroxyprogesterone acetate injections
- C. A female condom with nonoxynol-9
- D. A diaphragm
Correct Answer: C
Rationale: IUDs offer no protection against STIs. They are recommended for women who are in a stable, mutually monogamous relationship. Depot-medroxyprogesterone acetate (Depo-Provera) is a long-acting progestin that is highly effective for birth control. A single injection will provide contraception for 3 months but does not offer protection against STIs. A female condom does provide protection against some of the pathogens that cause STIs, and it would be readily available over the counter. A diaphragm offers no protection against STIs.
The nurse advises the client to avoid which medication during pregnancy?
- A. Acetaminophen
- B. Aspirin
- C. Prenatal vitamins
- D. Iron supplements
Correct Answer: B
Rationale: Aspirin is generally avoided in pregnancy due to risks of bleeding and fetal complications, unlike acetaminophen, which is safer.
The nurse assesses the fundal height for multiple pregnant clients. For which client should the nurse conclude that a fundal height measurement is most accurate?
- A. The pregnant client with uterine fibroids
- B. The pregnant client who is obese
- C. The pregnant client with polyhydramnios
- D. The pregnant client experiencing fetal movement
Correct Answer: D
Rationale: Excessive fetal movement may make it difficult to measure the client’s fundal height; however, it should not cause an inaccuracy in the measurement. Fibroids can increase fundal height and give a false measurement. Obesity can increase fundal height and give a false measurement. Polyhydramnios can increase fundal height and give a false measurement.
The nurse is counseling the client who has SLE. The client tells the nurse that she plans to become pregnant in the next year. Which response by the nurse is correct?
- A. “It is best to plan for your pregnancy when you have been in remission for 6 months.”
- B. “Having systemic lupus erythematosus will not impact your pregnancy in any way.”
- C. “Your chances of having an infant with congenital malformations are increased with SLE.”
- D. “You will need to be scheduled for a cesarean delivery to prevent disease transmission.”
Correct Answer: A
Rationale: Planning for pregnancy with SLE when in remission for 6 months is correct. Pregnancy planned during periods of inactive or stable disease often results in giving birth to a healthy full-term baby without increased risks of pregnancy complications. Exacerbations of SLE can occur during pregnancy and impact pregnancy outcomes. There is no risk of congenital malformations associated with maternal SLE. However, the risk for spontaneous abortion, preterm labor and birth, and neonatal death is increased. SLE is not a transmissible disease, and there is no reason for a cesarean delivery.