Nokea
The nurse is teaching the postpartum client, who is breastfeeding, about returning to sexual activity after vaginal delivery. Which statement should the nurse include?
- A. “Orgasm may decrease the amount of breast milk you produce.”
- B. “You may need to use lubrication when resuming sexual intercourse.”
- C. “You should not have sexual intercourse until two months postpartum.”
- D. “Your HCP will let you know when you can resume sexual activity.”
Correct Answer: B
Rationale: Oxytocin is released when the client has an orgasm and may cause breast milk to leak or squirt from the breasts. The production of breast milk may increase, not decrease. The nurse should inform the client that she may need lubrication with sexual intercourse because the low estrogen levels in the early postpartum period causes vaginal dryness. Women should refrain from sexual intercourse until lochia has ceased, which usually takes about 3 weeks. There is no need to wait two months if the lochia has ceased. The client’s HCP does not need to give approval to return to sexual activity.
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The nurse is caring for multiple clients. The nurse determines that which client would be a candidate for intermittent fetal monitoring during labor?
- A. The client with a previous cesarean birth
- B. The primigravida client at 41 weeks
- C. The client with preeclampsia
- D. The client with gestational diabetes
Correct Answer: B
Rationale: The client who is overdue by 7 days but has a reassuring FHR pattern is able to have intermittent fetal monitoring. Women with a previous cesarean birth are at an increased risk for uterine rupture. Women with preeclampsia are at an increased risk for placental insufficiency and need continuous monitoring during labor. Women with gestational diabetes are at an increased risk for placental insufficiency and need continuous monitoring during labor.
After gathering further information about the edema, the nurse advises the client to limit the intake of which substance?
- A. Sodium
- B. Potassium
- C. Vitamin C
- D. Magnesium
Correct Answer: A
Rationale: Limiting sodium intake helps reduce fluid retention, which contributes to edema in pregnancy.
The laboring client is at 5/100/0, RCA, and having difficulty coping with her contractions. She does not want an epidural analgesia or medications. How can the nurse best assist the client and her partner at this time?
- A. Apply counter pressure to sacral area with a firm object.
- B. Implement effleurage (light massage) of the abdomen.
- C. Provide a quiet, calm, and relaxed labor environment.
- D. Re-emphasize modified-paced breathing techniques.
Correct Answer: D
Rationale: Breathing techniques provide distraction, reduce pain perception, and help the client maintain control during labor. The modified-paced breathing technique is usually more effective during active labor (4—7 cm). The client is at 5 cm. The modified-paced technique is performed at about twice the normal breathing rate and requires that the client remain alert and concentrate fully on her breathing. Counter pressure can be helpful to cope with internal pressure sensations and pain in the lower back when the fetus is in posterior position. The fetus is ROA or right occiput anterior position. Effleurage can distract from contraction pain during the latent phase of the first stage of labor. This client is in active labor, and as labor progresses, hyperesthesia occurs, increasing the likelihood that effleurage will be uncomfortable and less effective. Providing a quiet, calm, and relaxed labor environment should be part of the nursing responsibilities to help the client cope with contractions, but this is not the best option.
The laboring client just had a convulsion after being given regional anesthesia. Which interventions should the nurse implement? Select all that apply.
- A. Establish an airway.
- B. Position on her right side.
- C. Provide 100% oxygen.
- D. Administer diazepam.
- E. Page the anesthesiologist STAT.
Correct Answer: A,C,D,E
Rationale: The client experiencing a convulsion related to anesthesia should first have an airway established. The client experiencing a convulsion related to anesthesia should receive 100% oxygen so that the mother and fetus remain oxygenated. Small doses of diazepam or thiopental can be administered to stop the convulsions. The anesthesiologist should be STAT paged to provide assistance; the convulsion was initiated by the regional anesthetic. The client’s head should be turned to the side if vomiting occurs, but the client typically remains in a left lateral tilt position so an airway can be maintained. Positioning on the right side can cause aortocaval compression.
The client tells the nurse, “Most days, I am so happy I am pregnant, but other days, I am not sure that I am ready to have a baby.” Which is the most accurate response from the nurse?
- A. “This is such a happy time in your life. You need to be optimistic to feel happy.”
- B. “How does your spouse feel about the pregnancy? I hope he is happy about the baby.”
- C. “Feeling differently from day to day is normal. How do you feel today?”
- D. “Why do you feel this way? Is there something I can do to make it better for you?”
Correct Answer: C
Rationale: It is most therapeutic to acknowledge the client’s feelings and probe for more information on her thoughts and feelings about the pregnancy. Not all clients consider pregnancy a happy time in their lives, and the nurse should never tell the client how to feel. The nurse should not divert the client’s concerns away from self by bringing up the father’s adaptation to the pregnancy, even though paternal adaptation is related to maternal adaptation. The client may not be able to identify why she has the feelings she is experiencing or how the nurse can make her feel better. This response does not provide an avenue for further exploration of the client’s concerns.