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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A client at 15 weeks' gestation is admitted with dark brown vaginal bleeding and continuous nausea and vomiting. Her blood pressure is 142/98 and fundal height is 19 cm. The nurse should prepare to do which of the following?
- A. Transfer the client to the antenatal unit.
- B. Keep the client NPO for 24 hours.
- C. Administer magnesium sulfate.
- D. Obtain an ultrasound.
Correct Answer: D
Rationale: Ultrasound confirms the diagnosis of a hydatidiform mole.
The nurse is caring for a primipara in active labor when the fetus develops severe bradycardia with late decelerations, and an emergency cesarean delivery is performed with the client under general anesthesia. After the delivery, the client tells the nurse, 'I feel terrible. This is exactly what I didn't want to happen!' Which of the following is a priority nursing diagnosis for this client?
- A. Interrupted family processes related to cesarean delivery.
- B. Anxiety related to incisional scar and neonatal outcome.
- C. Pain related to surgical incision and uterine cramping.
- D. Situational low self-esteem related to inability to deliver vaginally.
Correct Answer: D
Rationale: The client's statement reflects disappointment and possible feelings of failure due to the unplanned cesarean, making situational low self-esteem the priority. Pain, anxiety, and family processes are secondary concerns post-delivery.
A newborn is diagnosed with fetal alcohol syndrome. The nurse is teaching this mother what to expect when she goes home with her baby. The nurse determines the mother needs further instruction when she says which of the following?
- A. The way my baby's face looks now will stay that way.'
- B. My baby may be irritable as a newborn.'
- C. I may need some help coping with my newborn.'
- D. My baby will be fine soon after we are home.'
Correct Answer: D
Rationale: FAS is a lifelong condition, and the neonate will not be 'fine' soon after going home, indicating a need for further instruction.
A client in sickle cell crisis has been hospitalized during her pregnancy. After giving discharge instructions, the nurse determines the client needs further teaching when she states which of the following?
- A. "I will need more frequent appointments during the remainder of the pregnancy."
- B. "Signs of any type of infection must be reported immediately."
- C. "At the earliest signs of a crisis, I need to seek treatment."
- D. "I have this disease because I don't eat enough food with iron."
Correct Answer: D
Rationale: Sickle cell disease is genetic, not caused by dietary iron deficiency.
Which of the following client statements indicates effective teaching about burping a breastfed neonate?
- A. Breast-fed babies who are burped frequently will take more on each breast.
- B. If I supplement the baby with formula, I will rarely have to burp him.
- C. I'll breast-feed my baby every 3 hours so I won't have to burp him.
- D. When I switch to the other breast, I'll burp the baby.
Correct Answer: D
Rationale: Burping when switching breasts helps release air and promotes effective feeding.