Nokea
The nurse teaches the client to recognize which early labor sign?
- A. Bloody show
- B. Fatigue
- C. Increased appetite
- D. Mild nausea
Correct Answer: A
Rationale: Bloody show, a mucous discharge tinged with blood, is a common early labor sign as the cervix begins to dilate.
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The nurse is caring for the 24-year-old client whose pregnancy history is as follows: elective termination age 18 years, spontaneous abortion age 21 years, term vaginal delivery at 22 years old, and currently pregnant again. Which documentation by the nurse of the client’s gravidity and parity is correct?
- A. G4P1
- B. G4P2
- C. G3P1
- D. G2P1
Correct Answer: A
Rationale: The client has been pregnant four times in all (gravidity). This client has delivered once (parity) and is currently pregnant, so the parity is 1. Although the client has been pregnant four times in all (gravidity), she would have had to deliver two fetuses over 20 weeks old, regardless of whether either fetus survived. The client has been pregnant four times in all, not three (gravidity). Parity of 1 is correct. The client has been pregnant four times in all, not two times (gravidity). Parity of 1 is correct.
On the basis of the client's statement, what can the nurse conclude?
- A. The client is having twins.
- B. The client is between 14 and 18 weeks' gestation.
- C. The client is in the first trimester.
- D. The client's due date will be difficult to calculate.
Correct Answer: B
Rationale: Fetal movement in a multigravida is typically felt earlier, around 14-18 weeks, aligning with the client's report.
The nurse explains to the group that frequent urination during early pregnancy usually subsides at which time?
- A. When the placenta is fully developed
- B. When fetal kidneys begin to function
- C. When the uterus rises into the abdominal cavity
- D. When the hormonal balance is reestablished
Correct Answer: C
Rationale: Frequent urination subsides in the second trimester as the uterus rises into the abdominal cavity, reducing bladder pressure.
Two days after hospital discharge, the nurse is assessing the mother and her newborn twins in their home. Which statement or question made by the nurse best demonstrates empathy?
- A. “You may be feeling overwhelmed. This is normal.”
- B. “I can’t imagine how tired you must be with twins.”
- C. “How are you feeling about being the mother of twins?”
- D. “I saw that laundry is piling up. Do you want a home aide?”
Correct Answer: C
Rationale: Projecting feelings onto the client does not demonstrate empathy. This statement imposes a personal assumption and does not demonstrate empathy. This question demonstrates empathy. The nurse is asking a question to allow the client to explain her situation and feelings while the nurse listens. The nurse is attempting to understand the experience as lived by the client. Acknowledging that laundry is piling up and offering home aide services do not demonstrate empathy. Commenting on the laundry on the first visit may suggest to the client that she lacks support, and she may be defensive or hurt by the acknowledgement.
The client has a vaginal delivery of a full-term newborn. Immediately after delivery, the nurse assesses that the client’s perineum and labia are edematous, but she does not have an episiotomy or a perineal laceration. Which intervention should the nurse implement?
- A. Give her an ice pack to apply to the perineum.
- B. Teach her to relax her buttocks before sitting.
- C. Apply warm packs to the affected areas.
- D. Provide a plastic donut cushion for sitting.
Correct Answer: A
Rationale: If perineal edema is present, ice packs should be applied for the first 24 hours. Ice reduces edema and vulvar irritation. The client should be taught to tighten, not relax, her buttocks when sitting. This compresses the buttocks and reduces pressure on the perineum. After 24 hours, heat is recommended to increase circulation to the area. Donut cushions should be avoided because they promote separation of the buttocks and decrease venous blood flow to the area, thus increasing pain.