Nokea
The postpartum client delivered a healthy newborn 36 hours previously. The nurse finds the client crying and asks what is wrong. The client replies, “Nothing, really. I’m not in pain or anything, but I just seem to cry a lot for no reason.” What should be the nurse’s first intervention?
- A. Call the client’s support person to come and sit with her.
- B. Remind her that she has a healthy baby and that she shouldn’t be crying.
- C. Contact the HCP to have the counselor come see the client.
- D. Ask the client to discuss her birth experience.
Correct Answer: D
Rationale: The client’s support person should be given information about postpartum blues before the client is discharged from the hospital. However, contacting that individual should not be the first intervention. Reminding the client that she has a healthy baby is a nontherapeutic communication technique that implies disapproval of the client’s actions. There is no need to notify the HCP, as postpartum blues is a common self-limiting postpartum occurrence. A key feature of postpartum blues is episodic tearfulness without an identifiable reason. Interventions for postpartum blues include allowing the client to relive her birth experience.
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The nurse is teaching the client who is wishing to travel by airplane during the first 36 weeks of her pregnancy. Which is the primary risk of air travel for this client that the nurse should address?
- A. Risk of preterm labor
- B. Deep vein thrombosis
- C. Spontaneous abortion
- D. Nausea and vomiting
Correct Answer: B
Rationale: The primary risk with air travel during pregnancy is DVT. Pregnancy increases the risk of blood coagulation, and prolonged sitting produces venous stasis. Preterm labor is not associated with air travel. The threat of spontaneous abortion diminishes during the second trimester. Spontaneous abortion is not associated with air travel. Although nausea and vomiting can occur, they are not dangerous.
The nurse is caring for the pregnant client. The nurse identifies that the use of which street drug places the client at risk for placental abruption?
- A. Heroin
- B. Marijuana
- C. Oxycodone
- D. Cocaine
Correct Answer: D
Rationale: The most commonly used drug that places the pregnant client at risk for placental abruption is cocaine. Stillbirth, preterm labor and birth, and small for gestational age are also associated with cocaine use during pregnancy. Heroin use during pregnancy is associated with intrauterine growth restriction, spontaneous abortion, preterm labor and birth, and stillbirth. Marijuana use during pregnancy is primarily associated with intrauterine growth restriction. Oxycodone (OxyContin) is synthetic morphine, and its use during pregnancy is associated with intrauterine growth restriction, spontaneous abortion, preterm labor and birth, and stillbirth.
The nurse is evaluating the client in triage for possible labor. The client’s contractions are every 3 to 4 minutes, 60 to 70 seconds in duration, and moderate by palpation. Her cervical exam in the office was illustration 1. Her current exam is illustration 2. What conclusions should the nurse draw from illustration 2?
- A. The client is not dilated or effaced.
- B. The client is completely dilated but not effaced.
- C. The client has minimally dilated, but completely effaced.
- D. The client is not dilated, but completely effaced.
Correct Answer: C
Rationale: In illustration 2, the client is completely effaced and has some dilation. Illustration 1 (not illustration 2) shows that the client is neither effaced nor dilated. The cervical opening is minimally dilated, not completely dilated, and completely effaced. Illustration 2 shows some dilation.
The nurse is caring for the pregnant client at the initial prenatal visit. Which universal screenings should the nurse complete? Select all that apply.
- A. Taking the client’s blood pressure
- B. Doing a urine dipstick test for protein
- C. Doing a urine dipstick test for glucose
- D. Asking questions about domestic violence
- E. Asking questions about use of tobacco
Correct Answer: A,D,E
Rationale: BP screening should be performed at the initial prenatal visit to establish a baseline and to evaluate for actual or potential problems. Domestic violence screening should be performed at the initial prenatal visit to determine fetal and maternal risk for harm. Screening for tobacco use should be performed at the initial prenatal visit to determine fetal and maternal risk. Smoking is associated with an increased risk for spontaneous abortion, preterm labor, and low birth weight. The use of routine urine dip assessments is unreliable in detecting proteinuria and is not always considered accurate. A urine sample should be collected and a UA completed to check for a UTI. The urine dipstick test is of insufficient sensitivity to be used as a screening tool for glycosuria and is not always considered accurate. A urine sample should be collected and a UA completed to check for the presence of glucose.
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.