Nokea
The nurse is performing effleurage for a primigravid client in early labor. The nurse should do which of the following?
- A. Deep kneading of superficial muscles.
- B. Secure grasping of muscular tissues.
- C. Light stroking of the skin surface.
- D. Prolonged pressure on specific sites.
Correct Answer: C
Rationale: Effleurage is a light, stroking massage of the skin surface (often the abdomen) to promote relaxation and pain relief during labor. Deep kneading, grasping, or prolonged pressure describe other massage techniques not specific to effleurage.
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Assessment of a 16-year-old nulligravid client who visits the clinic and asks for information on contraceptives reveals a menstrual cycle of 28 days. The nurse formulates a nursing diagnosis of Deficient knowledge related to ovulation and fertility management. Which of the following would be important to include in the teaching plan for the client?
- A. The ovum survives for 96 hours after ovulation, making conception possible during this time.
- B. The basal body temperature falls at least 0.2°F after ovulation has occurred.
- C. Ovulation usually occurs on day 14, plus or minus 2 days, before the onset of the next menstrual cycle.
- D. Most women can tell they have ovulated because of severe pain and thick, scant cervical mucus.
Correct Answer: C
Rationale: Ovulation typically occurs around day 14 (plus or minus 2 days) before the next menstrual cycle in a 28-day cycle, which is critical for understanding fertility windows. The ovum survives for about 12-24 hours, not 96 hours, and basal body temperature rises after ovulation.
A 30-year-old multigravid client at 8 weeks' gestation has a history of insulin-dependent diabetes since age 20. When explaining about the importance of blood glucose control during pregnancy, the nurse should tell the client that which of the following will occur regarding the client's insulin needs during the first trimester?
- A. They will increase.
- B. They will decrease.
- C. They will remain constant.
- D. They will be unpredictable.
Correct Answer: B
Rationale: Insulin needs typically decrease in the first trimester due to increased insulin sensitivity.
A multigravid client at 38 weeks' gestation, G4 P3, is 6 cm dilated with contractions every 3 minutes. The nurse observes meconium-stained amniotic fluid after spontaneous rupture of membranes. What is the priority nursing action?
- A. Prepare for immediate cesarean delivery.
- B. Assess the fetal heart rate pattern.
- C. Suction the client's oropharynx.
- D. Document the fluid characteristics.
Correct Answer: B
Rationale: Meconium-stained fluid raises the risk of fetal distress. Assessing the fetal heart rate pattern immediately ensures the fetus is tolerating labor. Cesarean delivery is not automatic, suctioning is irrelevant, and documentation follows assessment.
A nurse is counseling a client about the vaginal contraceptive ring. Which of the following client statements indicates a need for further teaching?
- A. I will leave the ring in place for three weeks.
- B. I may experience nausea or breast tenderness.
- C. I can remove the ring for up to 3 hours if needed.
- D. The ring will make my periods heavier.
Correct Answer: D
Rationale: The vaginal contraceptive ring typically reduces menstrual flow or causes lighter periods, not heavier ones. The other statements are correct, indicating a need for further teaching about menstrual effects.
A male neonate born at 36 weeks' gestation is admitted to the neonatal intensive care nursery with a diagnosis of probable fetal alcohol syndrome (FAS). The mother visits the nursery soon after the neonate is admitted. Which of the following instructions should the nurse expect to include when developing the teaching plan for the mother about FAS?
- A. Withdrawal symptoms usually do not occur until 7 days postpartum.
- B. Large-for-gestational-age size is common with this condition.
- C. Facial deformities associated with FAS can be corrected by plastic surgery.
- D. Symptoms of withdrawal include tremors, sleeplessness, and seizures.
Correct Answer: D
Rationale: Symptoms of withdrawal in FAS include tremors, sleeplessness, and seizures due to neurological effects of alcohol exposure.