Nokea
The nurse is reviewing the laboratory test results of the pregnant client. Which laboratory test findings would require further follow-up from the nurse?
- A. Hemoglobin
- B. 50-g, 1-hour glucose test
- C. Glucosuria
- D. Proteinuria
Correct Answer: A
Rationale: The normal Hgb level should be 12—16 g/dL in the pregnant client. The nurse should encourage iron-rich foods. The 50-g 1-hour glucose test should be less than 140. Values over 140 warrant a 3-hour glucose screen to determine if the client has gestational diabetes. The presence of glucose in the urine (glucosuria) is negative, which is a normal finding. Proteinuria in trace amounts is common in pregnant women, although higher protein concentrations should be evaluated.
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When the client asks the nurse about the viability of the ovum after ovulation, the nurse correctly explains that after ovulation, the ovum remains alive for how many hours?
- A. 2 hours
- B. 24 hours
- C. 48 hours
- D. 72 hours
Correct Answer: B
Rationale: The ovum remains viable for approximately 24 hours after ovulation, during which it can be fertilized by sperm.
When looking in the mirror at her abdomen, the postpartum client says to the nurse, “My stomach still looks like I’m pregnant!” The nurse explains that the abdominal muscles, which separate during pregnancy, will undergo which change?
- A. Regain tone Within the first week after birth
- B. Regain prepregnancy tone with exercise
- C. Remain separated, giving the abdomen a slight bulge
- D. Regain tone as the weight gained during pregnancy is lost
Correct Answer: B
Rationale: For most women, it takes about 6 weeks (not one week) to regain abdominal wall muscle tone to the prepregnancy state, and usually only with exercise. The “still-pregnant” appearance is caused by relaxation of the abdominal wall muscles. With exercise, most women can regain prepregnancy abdominal muscle tone within about 6 weeks. If the client delivers a very large infant, the abdominal muscles may separate, but the separation will become less apparent over time. Weight loss alone will not strengthen the abdominal muscles.
The client delivered a healthy newborn 4 hours ago after being induced with oxytocin. While being assisted to the bathroom to void for the first time after delivery, the client tells the nurse that she doesn’t feel a need to urinate. Which explanation should the nurse provide when the client expresses surprise after voiding 900 mL of urine?
- A. “A decreased sensation of bladder filling is normal after childbirth.”
- B. “The oxytocin you received in labor makes it difficult to feel voiding.”
- C. “You probably didn’t empty completely. I will need to scan your bladder.”
- D. “Your bladder capacity is large; you likely won’t void again for 6—8 hours.”
Correct Answer: A
Rationale: The nurse should explain about the decreased sensation of bladder filling after childbirth. It is not uncommon for the postpartum client to have increased bladder capacity, decreased sensitivity to fluid pressure, and a decreased sensation of bladder filling. Oxytocin (Pitocin) is not expected to cause a change in bladder sensation, but it does have an antidiuretic effect. There is no indication that the client didn’t completely empty; a volume of 900 mL is a large amount. The postpartum client is at risk for bladder overdistention and should be encouraged to void every 2 to 4 hours.
The nurse correctly explains to the group that the discomfort associated with varicose veins is relieved by which activity?
- A. Resting with the feet in a dependent position
- B. Sitting for periods of time when possible
- C. Putting on calf-length, elastic-top hose
- D. Moving around after standing in one position
Correct Answer: C
Rationale: Elastic-top hose improves venous return, reducing discomfort from varicose veins, unlike dependent positioning or sitting.
The nurse explained the process of cervical effacement to the client in early labor. Which statement by the client indicates that she understands the information?
- A. “The cervix will widen from less than 1 cm to about 10 cm.”
- B. “The cervix will pull or draw up and become paper-thin.”
- C. “The cervical changes will cause my membranes to rupture.”
- D. “The cervical changes will help my baby to change position.”
Correct Answer: B
Rationale: In cervical effacement, the cervix progressively changes from a thick and long structure, to paper thin. This statement indicates that the client understands the information. Widening of the cervix describes cervical dilation, not effacement. Cervical changes will not cause membranes to rupture. The power of contractions causes cervical changes (effacement and dilation) and, possibly, membrane rupture. Cervical changes will not help the fetus to change position. Fetal descent is thought to occur from the pressure of contractions, especially from the fundus, and from the pressure of the amniotic fluid. Fetal position changes also occur from the fetal head and body adjusting to the maternal pelvis as they descend.