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The physician orders scalp stimulation of the fetal head for a primigravid client in active labor. When explaining to the client about this procedure, which of the following would the nurse include as the purpose?
- A. Assessment of the fetal hematocrit level.
- B. Increase in the strength of the contractions.
- C. Increase in the fetal heart rate and variability.
- D. Assessment of fetal position.
Correct Answer: C
Rationale: Scalp stimulation is used to assess fetal well-being by eliciting a heart rate acceleration, indicating good oxygenation and variability. It does not assess hematocrit, strengthen contractions, or determine position.
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A nurse is teaching a client about the use of spermicides. Which of the following client statements indicates understanding?
- A. Spermicide should be applied 10-30 minutes before intercourse.
- B. Spermicide is effective for up to 24 hours.
- C. Spermicide provides protection against STIs.
- D. Spermicide is most effective when used alone.
Correct Answer: A
Rationale: Spermicide should be applied 10-30 minutes before intercourse for optimal effectiveness. It is effective for about 1 hour, does not protect against STIs, and is most effective with barrier methods.
For the past 8 hours, a 20-year-old primigravid client in active labor with intact membranes has been experiencing regular contractions. The fetal heart rate is 136 bpm with good variability. After determining that the client is still in the latent phase of labor, the nurse should observe the client for:
- A. Exhaustion.
- B. Chills and fever.
- C. Fluid overload.
- D. Meconium-stained fluid.
Correct Answer: A
Rationale: Prolonged latent phase (8 hours) in a primigravid client can lead to maternal exhaustion due to sustained effort and lack of progress, impacting labor stamina. Chills/fever, fluid overload, or meconium-stained fluid are less likely without specific risk factors.
Which of the following should the nurse include in the discharge teaching for a primiparous client about preventing postpartum infections?
- A. Change perineal pads every 8 hours.
- B. Take warm sitz baths twice daily.
- C. Wash hands before and after perineal care.
- D. Use a hairdryer to dry the perineal area.
Correct Answer: C
Rationale: Hand washing before and after perineal care reduces the risk of introducing pathogens, preventing infections.
A client asks about the disadvantages of the vaginal contraceptive ring. Which of the following would the nurse include?
- A. It requires daily insertion.
- B. It may cause nausea or breast tenderness.
- C. It is less effective than condoms.
- D. It causes permanent infertility.
Correct Answer: B
Rationale: The vaginal contraceptive ring may cause nausea or breast tenderness, especially initially. It is inserted once every 3 weeks, is more effective than condoms when used correctly, and does not cause permanent infertility.
After a vaginal delivery of a term neonate, the nurse observes that the neonate has one artery and one vein in the umbilical cord. The nurse notifies the pediatrician based on the analysis that this may be indicative of ?
- A. Respiratory anomalies.
- B. Musculoskeletal anomalies.
- C. Cardiovascular anomalies.
- D. Facial anomalies.
Correct Answer: C
Rationale: A single umbilical artery is associated with an increased risk of cardiovascular anomalies, warranting further evaluation.