Nokea
To determine whether a primigravid client in labor with a fetus in the left occipitoanterior (LOA) position is completely dilated, the nurse performs a vaginal examination. During the examination the nurse should palpate which of the following cranial sutures?
- A. Sagittal.
- B. Lambdoidal.
- C. Coronal.
- D. Frontal.
Correct Answer: A
Rationale: In the LOA position, the fetus's occiput is anterior, and the sagittal suture (running midline along the skull) is most accessible during vaginal examination to assess dilation and fetal position. Other sutures are less prominent in this presentation.
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After instructing a multigravid client diagnosed with mild preeclampsia how to keep a record of fetal movement patterns at home, the nurse determines that the teaching has been effective when the client says that she will count the number of times the baby moves during which of the following time spans?
- A. 30-minute period three times a day.
- B. 45-minute period after lunch each day.
- C. 1-hour period each day.
- D. 12-hour period each week.
Correct Answer: C
Rationale: Counting fetal movements for one hour daily is a common method to monitor fetal well-being.
A nurse is teaching a client about the use of female condoms. Which of the following instructions should the nurse include?
- A. Insert the female condom up to 8 hours before intercourse.
- B. Reuse the female condom if it is undamaged.
- C. Apply spermicide to the female condom for added protection.
- D. Store female condoms in a hot environment.
Correct Answer: A
Rationale: The female condom can be inserted up to 8 hours before intercourse, providing flexibility. It cannot be reused, does not require spermicide for effectiveness, and should be stored in a cool, dry place.
The nurse is performing effleurage for a primigravid client in early labor. The nurse should do which of the following?
- A. Deep kneading of superficial muscles.
- B. Secure grasping of muscular tissues.
- C. Light stroking of the skin surface.
- D. Prolonged pressure on specific sites.
Correct Answer: C
Rationale: Effleurage is a light, stroking massage of the skin surface (often the abdomen) to promote relaxation and pain relief during labor. Deep kneading, grasping, or prolonged pressure describe other massage techniques not specific to effleurage.
A neonate delivered at 40 weeks' gestation admitted to the nursery is found to be hypoglycemic. At 4 hours of age, the neonate appears pale and his pulse oximeter is reading 75 %. The nurse should:
- A. Increase the I.V. rate.
- B. Provide supplemental oxygen.
- C. Record the finding on the chart and repeat the reading in 30 minutes.
- D. Wrap the neonate to increase body temperature.
Correct Answer: B
Rationale: A pulse oximetry reading of 75% indicates hypoxemia, and providing supplemental oxygen is the priority.
Following a cesarean delivery for abruptio placentae, a multigravid client tells the nurse, "I feel like such a failure. None of my other deliveries were like this." The nurse's response to the client is based on the understanding of which of the following?
- A. The client will most likely have postpartum blues.
- B. Maternal-infant bonding is likely to be difficult.
- C. The client's feeling of grief is a normal reaction.
- D. This type of delivery was necessary to save the client's life.
Correct Answer: C
Rationale: Grief is a normal reaction to a complicated delivery.