Nokea
The nurse is preparing a client for induction of labor. What is the purpose of administering oxytocin?
- A. Stimulate uterine contractions.
- B. Relieve pain during labor.
- C. Promote cervical ripening.
- D. Reduce maternal blood pressure.
Correct Answer: A
Rationale: The correct answer is A: Stimulate uterine contractions. Oxytocin is administered to induce labor by increasing the frequency and strength of uterine contractions. This helps progress labor and facilitate delivery. Choice B is incorrect as pain relief is usually achieved through analgesics or anesthesia. Choice C is incorrect because cervical ripening is typically promoted with medications like prostaglandins. Choice D is also incorrect as oxytocin can actually cause a temporary increase in blood pressure.
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Which statement by the client would alert the nurse that she should not take oral contraceptives?
- A. I drink one to two alcohol drinks a few times a week.
- B. I am slightly overweight and have a difficult time fitting exercise into my schedule.
- C. I am trying to limit cigarettes to one pack a week.
- D. I try to have my boyfriend wear a condom every time we have sex.
Correct Answer: C
Rationale: The correct answer is C because smoking while taking oral contraceptives increases the risk of blood clots, stroke, and heart attack. Smoking and oral contraceptives together pose a higher risk than either alone. Choices A, B, and D are not direct contraindications for taking oral contraceptives. A: Moderate alcohol consumption is generally not contraindicated. B: Being slightly overweight and having difficulty with exercise are not absolute contraindications. D: Using condoms is a good practice but does not specifically indicate a reason not to take oral contraceptives.
A nurse is assessing a client who is 3 days postpartum and is breastfeeding. The nurse notes that the fundus is three fingerbreadths below the umbilicus, lochia rubra is moderate, and the breasts are hard and warm to palpation. Which of the following interpretations of these findings should the nurse make?
- A. The client is exhibiting early indications of mastitis.
- B. Additional interventions are not indicated at this time.
- C. Application of a heating pad to the breasts is indicated.
- D. The client should be advised to remove her nursing bra.
Correct Answer: B
Rationale: Correct Answer: B - Additional interventions are not indicated at this time.
Rationale:
1. Fundus location: Three fingerbreadths below the umbilicus is within normal range for 3 days postpartum.
2. Lochia rubra: Moderate lochia rubra is expected at this stage postpartum.
3. Breasts: Hard and warm breasts are indicative of engorgement, a common issue in breastfeeding mothers.
Summary:
A: Early indications of mastitis would include redness, warmth, and tenderness in the breasts, along with flu-like symptoms.
C: Application of a heating pad to the breasts can worsen engorgement and increase the risk of mastitis.
D: Removing a nursing bra may offer some relief for engorgement, but it is not the priority intervention at this time.
Many teens wait until the second or even third trimester to seek prenatal care. The nurse should understand that the reasons behind this delay include which of the following? (Select all that apply.)
- A. Continuing to deny the pregnancy
- B. Uncertainty about where to go for care
- C. Lack of realization that they are pregnant
- D. A desire to gain control over their situation
Correct Answer: A
Rationale: The correct answer is A: Continuing to deny the pregnancy. This is because some teens may struggle to come to terms with their pregnancy and deny it, leading to delays in seeking prenatal care. The other choices are incorrect. B: Uncertainty about where to go for care is not a common reason for delaying prenatal care as resources and information are usually available. C: Lack of realization that they are pregnant is unlikely as most teens eventually become aware of their pregnancy. D: A desire to gain control over their situation does not usually lead to delaying prenatal care as seeking care is a proactive step towards gaining control.
The nurse is preparing a client for an amniocentesis. What is the priority nursing action before the procedure?
- A. Administer IV fluids.
- B. Obtain baseline vital signs.
- C. Ensure informed consent is signed.
- D. Position the client in the Trendelenburg position.
Correct Answer: C
Rationale: The correct answer is C: Ensure informed consent is signed. Before any invasive procedure like an amniocentesis, it is essential to ensure that the client has full understanding of the risks, benefits, and alternatives. This is crucial for autonomy and ethical practice. Administering IV fluids (choice A) is not a priority before an amniocentesis. Obtaining baseline vital signs (choice B) is important but not the priority over informed consent. Positioning the client in the Trendelenburg position (choice D) is not necessary for an amniocentesis procedure.
A client at 20 weeks' gestation asks about fetal movements. What is the nurse's best response?
- A. Fetal movements are rarely felt before 24 weeks.
- B. You should feel strong, regular movements at this stage.
- C. You may feel fluttering movements, known as quickening.
- D. It is too early to feel any fetal movements.
Correct Answer: C
Rationale: The correct answer is C because quickening, described as fluttering movements, is typically felt by pregnant individuals around 18-20 weeks of gestation. This indicates fetal movement and is an important milestone in pregnancy. Choices A and D are incorrect as fetal movements can be felt as early as 18-20 weeks. Choice B is incorrect as feeling strong, regular movements is not expected until later in the pregnancy.