Nokea
The primigravida client has been pushing for 2 hours when the infant’s head emerges. The infant fails to deliver, and the obstetrician states that the turtle sign has occurred. Which should be the nurse’s interpretation of this information?
- A. There is cephalopelvic disproportion.
- B. The infant has a shoulder dystocia.
- C. The infant’s position is occiput posterior.
- D. The infant’s umbilical cord is prolapsed.
Correct Answer: B
Rationale: The “turtle sign” occurs when the infant’s head suddenly retracts back against the mother’s perineum after emerging from the vagina, resembling a turtle pulling its head back into its shell. This head retraction is caused by the infant’s anterior shoulder being caught on the back of the maternal pubic bone (shoulder dystocia), preventing delivery of the remainder of the infant. Cephalopelvic disproportion occurs when the head is too large to fit through the client’s pelvis. Fetal descent ceases, and infant’s head would not emerge. Persistent occiput posterior results in prolonged pushing; however, once the head is born, the remainder of the birth occurs without difficulty. A cord prolapse occurs when the umbilical cord enters the cervix before the fetal presenting part and is considered a medical emergency.
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Which statement made by a participant regarding remedies of heartburn and nausea indicates that teaching has been effective?
- A. I should eat frequent, small meals.
- B. I should take an antacid after eating.
- C. I should eat my largest meal in the evening.
- D. I should drink extra water with my meals.
Correct Answer: A
Rationale: Frequent, small meals reduce stomach acid and nausea, unlike large meals or extra water, which may worsen symptoms.
The nurse responds that, for clients with uncomplicated pregnancies, it is usually best to plan monthly visits for the first 28 weeks and then more frequent visits following which schedule?
- A. Weekly for the remainder of the pregnancy
- B. Every 2 weeks for the remainder of the pregnancy
- C. Every 2 weeks up to 36 weeks, then weekly for the last month
- D. Weekly up to 36 weeks, then twice weekly for the last month
Correct Answer: C
Rationale: Standard prenatal care involves monthly visits until 28 weeks, biweekly until 36 weeks, and weekly thereafter for uncomplicated pregnancies.
The nurse is caring for the Muslim client in labor. What should the nurse be most aware of as a possible belief of the client?
- A. Male health care providers should enter the room after receiving permission from her husband.
- B. The client may prefer to eat only “hot” foods and to drink only special tea and warm water.
- C. Fathers, rather than female relatives, are usually present to provide support during the labor.
- D. She will be more likely to moan, scream, or cry out in pain during each labor contraction.
Correct Answer: A
Rationale: Some Muslim women are not comfortable with male HCPs and may prefer to have their husband in the room if a male is involved in care. Eating “hot” foods and drinking special tea and warm water are preferences of Hmong women from Laos and not those of Muslim women. The Muslim client may choose to have her husband, a male relative, or a female friend or relative provide support during childbirth, rather than her father. Muslim women are more likely to be silent and stoic during labor contractions, and not cry out in pain.
Twenty-four hours post—vaginal delivery, the postpartum client tells the nurse that she is concerned because she has not had a bowel movement (BM) since before delivery. Which action should be taken by the nurse?
- A. Document the data in the client’s health care records
- B. Notify the health care provider immediately
- C. Administer a laxative that has been prescribed pm
- D. Assess the client’s abdomen and bowel sounds
Correct Answer: A
Rationale: A spontaneous BM may not occur for 2 to 3 days after childbirth due to decreased muscle tone in the intestines during labor and the immediate postpartum period, possible prelabor diarrhea, and decreased food intake and dehydration during labor. Thus, documentation of the lack of a BM is the only action required. There is no need to notify the HCP for a normal finding. A laxative is unnecessary since a BM is not expected for 2 to 3 days postdelivery. Bowel sounds are not altered by a vaginal delivery, even though the passage of stool through the intestines is slowed.
While assessing the breastfeeding mother 24 hours postdelivery, the nurse notes that the client’s breasts are hard and painful. Which interventions should be implemented by the nurse? Select all that apply.
- A. Tell her to feed a small amount from both breasts at each feeding.
- B. Apply ice packs to the breasts at intervals between feedings.
- C. Give supplemental formula at least once in a 24-hour period.
- D. Administer an anti-inflammatory medication prescribed pm.
- E. Apply warm, moist packs to the breasts between feedings.
- F. Pump the breasts as needed to ensure complete emptying.
Correct Answer: B,D,F
Rationale: Moving the baby from the initial breast to the second breast during the feeding, before the initial breast is completely emptied, may result in neither breast being totally emptied and thus promote continued engorgement. Because engorgement is caused, in part, by swelling of the breast tissue surrounding the milk gland ducts, applying ice at intervals between feedings will help to decrease this swelling. Giving supplemental formula, thus limiting the time the baby nurses at the breast, prevents total emptying of the breast and promotes increased engorgement. Administering anti-inflammatory medication will decrease breast pain and inflammation. Because heat application increases blood flow, moist heat packs would exacerbate the engorgement. Pumping the breasts may be necessary if the infant is unable to completely empty both breasts at each feeding. Pumping at this time will not cause a problematic increase in breast milk production.