Nokea
The nurse should encourage the laboring client to begin pushing when
- A. There is only an anterior or posterior lip of cervix left
- B. The client describes the need to have a bowel movement
- C. The cervix is completely dilated
- D. The cervix is completely effaced
Correct Answer: C
Rationale: Pushing begins with the second stage of labor, i.e., when the cervix is completely dilated (C), the cervix can become edematous and may never completely dilate, necessitating an operative delivery. Many primigravidas begin active labor 100% effaced and then proceed to dilate.
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The nurse is teaching a client with gestational diabetes about nutrition and insulin need for pregnancy. Which content should the nurse include in this client teaching plan?
- A. Insulin production is decreased during pregnancy
- B. Increase daily caloric intake is needed
- C. Injection requirements remain the same
- D. Blood sugars need less monitoring in the first trimester
Correct Answer: B
Rationale: An increase in caloric intake is often necessary to meet the increased metabolic demands of pregnancy, especially in clients with gestational diabetes.
Following the vaginal delivery of a large-for-gestation-age (LGA) infant a woman is admitted to the intensive care unit due to postpartum hemorrhaging. The client's medical record lists the client's religion as Jehovah's Witness. What action should the nurse take?
- A. Prepare to infuse multiple units of fresh frozen plasma
- B. Inform the client of the critical need for a blood transfusion
- C. Clarify the clients wishes about receiving blood products
- D. Obtain consent from the family to infuse packed red blood cells
Correct Answer: C
Rationale: Clarifying the client's wishes regarding blood products (C) respects her religious beliefs.
Expectant parents ask a prenatal nurse educator, 'Which setting for childbirth limits the amount of parent-infant interaction?'
- A. Birth center
- B. Home birth
- C. Traditional hospital birth
- D. Labor, birth, and recovery room
Correct Answer: C
Rationale: In traditional hospital settings, the mother may see the infant for only short feeding periods, and the infant is cared for in a separate nursery.
A patient with a BMI of 32 has a positive pregnancy test. What is the maximum number of pounds that the nurse will advise the patient gain during the pregnancy?
- A. 20 lb
- B. 25 lb
- C. 28 lb
- D. 40 lb
Correct Answer: A
Rationale: The correct answer is A (20 lb). During pregnancy, the recommended weight gain for a woman with a BMI of 30-39.9 is 11-20 pounds. This range helps reduce the risk of complications associated with excessive weight gain. Option B (25 lb) exceeds this recommended range, while options C (28 lb) and D (40 lb) are even further beyond the healthy weight gain guidelines for a BMI of 32. Thus, advising the patient to gain a maximum of 20 pounds is the most appropriate recommendation to ensure a healthy pregnancy outcome.
A client at 39-weeks gestation is admitted to the labor and delivery unit in active labor. The client's cervix is dilated 5 cm, 90% effaced, and the fetus is at 0 station. The client's membranes rupture spontaneously, and the fluid is greenish-brown. What action should the nurse take first?
- A. Assess the fetal heart rate pattern.
- B. Perform a vaginal examination.
- C. Prepare for an emergency cesarean section.
- D. Administer oxygen via face mask.
Correct Answer: A
Rationale: Greenish-brown amniotic fluid indicates meconium-stained fluid, and assessing the fetal heart rate pattern is critical to determine fetal well-being.