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The physician who elects to perform a cesarean delivery on a primigravid client for fetal distress has informed the client of possible risks during the procedure. When the nurse asks the client to sign the consent form, the client's husband says, 'I'll sign it for her. She's too upset by what is happening to make this decision.' The nurse should:
- A. Ask the client if this is acceptable to her.
- B. Have the client and her husband both sign the consent form.
- C. Ask the client to sign the consent form.
- D. Ask the doctor to witness the consent form.
Correct Answer: C
Rationale: The client must provide informed consent unless incapacitated. The nurse should ask the client to sign, ensuring she understands despite her distress. The husband cannot sign unless legally authorized, and dual signatures or physician witnessing are unnecessary.
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When teaching a primiparous client about the growth and development of the neonate, which of the following should the nurse include as the usual age at which most babies are able to drink from a cup independently?
- A. 5 to 7 months.
- B. 8 to 10 months.
- C. 12 to 14 months.
- D. 15 to 16 months.
Correct Answer: C
Rationale: Most babies can drink from a cup independently by 12-14 months as motor skills develop.
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.
A nurse is discussing the contraceptive ring with a client. Which of the following client statements indicates understanding?
- A. I can remove the ring for up to 3 hours if needed.
- B. The ring is replaced every week.
- C. The ring requires daily insertion.
- D. The ring provides long-term contraception for 5 years.
Correct Answer: A
Rationale: The vaginal contraceptive ring can be removed for up to 3 hours if needed without losing effectiveness. It is replaced every 3 weeks (not weekly), not inserted daily, and provides contraception for one cycle, not 5 years.
The physician orders intermittent fetal heart rate monitoring for a 20-year-old obese primigravid client at 40 weeks' gestation who is admitted to the birthing center in the first stage of labor. The nurse should monitor the client's fetal heart rate pattern at which of the following intervals?
- A. Every 15 minutes during the latent phase.
- B. Every 30 minutes during the active phase.
- C. Every 60 minutes during the initial phase.
- D. Every 2 hours during the transition phase.
Correct Answer: B
Rationale: For a low-risk primigravid client in the active phase of the first stage of labor, intermittent fetal heart rate monitoring is typically performed every 30 minutes to ensure fetal well-being, as per standard obstetric guidelines. More frequent monitoring (every 15 minutes) is reserved for the second stage or high-risk cases, while less frequent intervals (every 60 minutes or 2 hours) are insufficient for active labor.
A nurse is teaching a client about the use of a cervical cap. Which of the following instructions should the nurse include?
- A. Leave the cervical cap in place for at least 6 hours after intercourse.
- B. Insert the cervical cap at least 1 hour before intercourse.
- C. Reuse the cervical cap without cleaning.
- D. Apply the cervical cap to the vaginal wall.
Correct Answer: A
Rationale: The cervical cap should be left in place for at least 6 hours after intercourse to ensure effectiveness. It can be inserted up to 6 hours before intercourse, must be cleaned after use, and is applied over the cervix, not the vaginal wall.