Nokea
The pregnant client (G1P0) in the first trimester tells the nurse that she is anxious about losing her baby, prenatal care, and her labor and birth. Which teaching need should the nurse identify as priority?
- A. Sexual relations with her spouse
- B. Fetal growth and development
- C. Options for labor and delivery
- D. Preparing needed items for the baby
Correct Answer: B
Rationale: Information about fetal growth and development is priority and important to address during the first trimester, especially when the client expresses concerns about losing her baby. There is no indication that sexual relations are a concern for the client. Sexual relations, including intercourse, are safe during the first trimester. Labor and delivery options for the baby are priorities in the third trimester. The completion of preparations for the baby is a priority in the third trimester.
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The nurse is assessing the Hispanic client who is in the active stage of labor. Which is the most crucial information that the nurse should assess related to the client’s ethnicity and stage of labor?
- A. Choice of pain control measures
- B. Desire for hot or cold fluids
- C. Persons to be in the room during labor and birth
- D. Desire for circumcision if a male infant is born
Correct Answer: A
Rationale: Because cultural variations exist in pain control measures used and pain tolerance, the most crucial assessment in the active stage of labor is the client’s choice of pain control measures. A desire for hot or cold fluids is an important aspect that should be determined during the early stage of labor. Determination of support persons is an important aspect that should be made during the early stage of labor. The desire for circumcision is an important consideration, but it is not the primary need during the active stage of labor.
The nurse is caring for the client who is being evaluated for a suspected malpresentation. The fetus’s long axis is lying across the maternal abdomen, and the contour of the abdomen is elongated. Which should be the nurse’s documentation of the lie of the fetus?
- A. Vertex
- B. Breech
- C. Transverse
- D. Brow
Correct Answer: C
Rationale: A transverse lie occurs in 1 in 300 births and is marked by the fetus’s lying in a side-lying position across the abdomen. Vertex presentations result in the lie’s being vertical. Breech presentations result in the lie’s being vertical. A brow presentation is also a vertical lie.
The laboring client tells the nurse that she wants to avoid an episiotomy if possible. Which response by the nurse is best?
- A. “Usually making an episiotomy incision is avoided whenever possible.”
- B. “Having an episiotomy reduces prolonged pushing and perineal trauma.”
- C. “An episiotomy is routine because it can prevent pelvic floor damage.”
- D. “Tell me more about your concerns about having an episiotomy.”
Correct Answer: A
Rationale: This statement is best. An episiotomy may be used in some circumstances but is usually avoided if possible. Use of episiotomy increases (not reduces) perineal trauma and increases healing time. Use of episiotomy is not routine, does not decrease pelvic floor damage, and may increase the severity of the trauma. Having the client tell the nurse more about her concerns regarding episiotomy is unnecessary and avoids responding to the client’s comment.
The nurse advises a client with a history of miscarriage to monitor which symptom?
- A. Mild fatigue
- B. Vaginal spotting
- C. Increased appetite
- D. Normal fetal movement
Correct Answer: B
Rationale: Vaginal spotting may indicate a threatened miscarriage, requiring close monitoring and medical evaluation.
The nurse teaches the client to report which postpartum symptom immediately?
- A. Mild cramping
- B. Foul-smelling lochia
- C. Light vaginal bleeding
- D. Fatigue after delivery
Correct Answer: B
Rationale: Foul-smelling lochia may indicate infection, requiring immediate reporting to prevent complications.