Nokea
The nurse is caring for the client who is being evaluated for a suspected malpresentation. The fetus’s long axis is lying across the maternal abdomen, and the contour of the abdomen is elongated. Which should be the nurse’s documentation of the lie of the fetus?
- A. Vertex
- B. Breech
- C. Transverse
- D. Brow
Correct Answer: C
Rationale: A transverse lie occurs in 1 in 300 births and is marked by the fetus’s lying in a side-lying position across the abdomen. Vertex presentations result in the lie’s being vertical. Breech presentations result in the lie’s being vertical. A brow presentation is also a vertical lie.
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The pregnant client presents with vaginal bleeding and increasing cramping. Her exam reveals that the cervical os is open. Which term should the nurse expect to see in the client’s chart notation to most accurately describe the client’s condition?
- A. Ectopic pregnancy
- B. Complete abortion
- C. Imminent abortion
- D. Incomplete abortion
Correct Answer: C
Rationale: In imminent abortion, the client’s bleeding and cramping increase and the cervix is open, which indicates that abortion is imminent or inevitable. In ectopic pregnancy, the pregnancy is outside of the uterus, and intervention is indicated to resolve the pregnancy. A complete abortion indicates that the contents of the pregnancy have been passed. In an incomplete abortion, a portion of the pregnancy has been expelled, and a portion remains in the uterus.
The pregnant client (G1P0) in the first trimester tells the nurse that she is anxious about losing her baby, prenatal care, and her labor and birth. Which teaching need should the nurse identify as priority?
- A. Sexual relations with her spouse
- B. Fetal growth and development
- C. Options for labor and delivery
- D. Preparing needed items for the baby
Correct Answer: B
Rationale: Information about fetal growth and development is priority and important to address during the first trimester, especially when the client expresses concerns about losing her baby. There is no indication that sexual relations are a concern for the client. Sexual relations, including intercourse, are safe during the first trimester. Labor and delivery options for the baby are priorities in the third trimester. The completion of preparations for the baby is a priority in the third trimester.
The nurse is caring for the postpartum primiparous client who is 13 hours post—vaginal delivery. The nurse observes that the client is passive and hesitant about making decisions about her own and her newborn’s care. In response to this observation, which interventions should be implemented by the nurse? Select all that apply.
- A. Question her closely about the presence of pain.
- B. Ask if she would like to talk about her birth experience.
- C. Encourage her to nap when her infant is napping.
- D. Encourage attendance in teaching sessions about infant care.
- E. Suggest that she begin to write her birth announcements.
Correct Answer: A,B,C
Rationale: Many women hesitate to ask for medication, as they believe their pain is expected. Thus, the nurse should ask the client about pain and assure her that there are methods to decrease her pain. During the initial postpartum “taking-in” phase, the client may have a great need to talk about her birthing experience and to ask questions for clarification as necessary. By encouraging this verbalization, the nurse helps the client to accept the experience and enables her to move to the next maternal phase. Physical discomfort can be intense initially postpartum and can interfere with rest. Sleep is a major need and should be encouraged. Anxiety and preoccupation with her new role often narrow the client’s perceptions, and information is not as easily assimilated at this time. Therefore, attending education sessions should be delayed if possible until the mother has completed this “taking in” phase. The client needs to suspend her involvement in everyday responsibilities during the “taking—in” phase, so writing birth announcements should be delayed until the mother has completed this phase.
The laboring client tells the nurse that she wants to avoid an episiotomy if possible. Which response by the nurse is best?
- A. “Usually making an episiotomy incision is avoided whenever possible.”
- B. “Having an episiotomy reduces prolonged pushing and perineal trauma.”
- C. “An episiotomy is routine because it can prevent pelvic floor damage.”
- D. “Tell me more about your concerns about having an episiotomy.”
Correct Answer: A
Rationale: This statement is best. An episiotomy may be used in some circumstances but is usually avoided if possible. Use of episiotomy increases (not reduces) perineal trauma and increases healing time. Use of episiotomy is not routine, does not decrease pelvic floor damage, and may increase the severity of the trauma. Having the client tell the nurse more about her concerns regarding episiotomy is unnecessary and avoids responding to the client’s comment.
The nurse is assessing the Hispanic client who is in the active stage of labor. Which is the most crucial information that the nurse should assess related to the client’s ethnicity and stage of labor?
- A. Choice of pain control measures
- B. Desire for hot or cold fluids
- C. Persons to be in the room during labor and birth
- D. Desire for circumcision if a male infant is born
Correct Answer: A
Rationale: Because cultural variations exist in pain control measures used and pain tolerance, the most crucial assessment in the active stage of labor is the client’s choice of pain control measures. A desire for hot or cold fluids is an important aspect that should be determined during the early stage of labor. Determination of support persons is an important aspect that should be made during the early stage of labor. The desire for circumcision is an important consideration, but it is not the primary need during the active stage of labor.