Nokea
A nurse in an obstetric clinic is caring for four clients.
The nurse should identify that an intrauterine device is contraindicated for which of the following clients?
- A. A client who has a history of gallbladder disease.
- B. A client who has a positive pregnancy test.
- C. A client who smokes one pack of cigarettes per day.
- D. A client who is allergic to latex.
Correct Answer: B
Rationale: A positive pregnancy test contraindicates IUD use as it risks harming the fetus and causing complications like miscarriage or infection.
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A nurse is caring for a client who had a vaginal delivery 4 hours ago and reports perineal pain of 6 on a scale of 0 to 10.
Which of the following actions should the nurse take?
- A. Catheterize the client's bladder.
- B. Apply a corticosteroid cream to the perineal area twice daily.
- C. Offer an ice pack to the client during the first 24 hours.
- D. Increase the client's fluid intake for 48 hours.
Correct Answer: C
Rationale: Offering an ice pack reduces swelling and numbs perineal pain, a standard intervention within the first 24 hours post-delivery.
A nurse in a provider's office is collecting data from a client who is at 34 weeks of gestation and reports having a sudden gush of vaginal fluid.
Which of the following manifestations is the priority?
- A. Maternal temperature 38.3°C (101°F).
- B. Fetal heart tones 98/min.
- C. Foul-smelling vaginal discharge.
- D. Amniotic fluid with meconium noted.
Correct Answer: B
Rationale: Fetal heart tones at 98/min are significantly lower than the normal range (110-160/min), indicating fetal distress and requiring immediate intervention.
A nurse is reinforcing teaching with a newly licensed nurse concerning a client on a postpartum unit following a cesarean birth.
Which of the following measures should the nurse include in the instructions to prevent thrombophlebitis?
- A. Have the client ambulate as often as possible.
- B. Apply warm, moist packs to the client's lower legs.
- C. Apply elastic stockings before the client gets out of bed.
- D. Administer NSAIDs every 6 to 8 hours.
Correct Answer: A
Rationale: Ambulation promotes venous return, preventing blood stasis and reducing thrombophlebitis risk after cesarean birth.
Nurses' Notes 0830: The client is a gravida 2 para 1 at 30 weeks of gestation. Reports low back pain and abdominal cramping for the past two days. History includes cesarean birth for breech presentation. Reports smoking half a pack of cigarettes per day. BMI is greater than 30. The client is grimacing and has a positive report of fetal movement. External electronic fetal monitoring applied, showing fetal heart rate of 148/min. The abdomen is soft and nontender to palpation. 0845: Uterine contractions every 2–3 minutes, moderate in strength. Sterile vaginal examination reveals cervix dilated to 2 cm, 80% effaced, and -1 station. Mucous vaginal discharge and a small amount of bright red bleeding noted on the perineal pad. Vital Signs: Temperature: 36.8°C (98.2°F), Heart rate: 98/min, Respiratory rate: 18/min, Blood pressure: 112/68 mm Hg, Oxygen saturation: 98% on room air.
For each finding, click to specify if the client finding is consistent with placenta previa, preterm labor, or abruptio placentae: A. Pain report, B. Uterine contractions, C. Perineal pad findings, D. Cervical dilation.
- A. Pain report
- B. Uterine contractions
- C. Perineal pad findings
- D. Cervical dilation
Correct Answer: A,B,C,D
Rationale: Pain and contractions suggest preterm labor/abruptio placentae; bleeding fits all three; dilation aligns with preterm labor/placenta previa.
A nurse is collecting data from a client who has hyperemesis gravidarum.
Which of the following findings should the nurse anticipate?
- A. Decreased pulse rate.
- B. Increased fundal height.
- C. Proteinuria.
- D. Poor skin turgor.
Correct Answer: D
Rationale: Poor skin turgor is anticipated in hyperemesis gravidarum due to dehydration from persistent vomiting, a hallmark sign.