Nokea
To which client is it most appropriate to recommend the intrauterine device (IUD)?
- A. Unmarried, 22-year-old, recent college graduate.
- B. Married, 24-year-old, G0 P0000.
- C. Unmarried, 25-year-old, history of chlamydia.
- D. Married, 26-year-old, G3 P2102.
Correct Answer: D
Rationale: IUDs are ideal for women in stable relationships with no history of PID.
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A nurse is assessing a client who is 8 hr postpartum and multiparous. Which of the following findings should alert the nurse to the client's need to urinate?
- A. Moderate lochia rubra
- B. Fundus three fingerbreadths above the umbilicus
- C. Moderate swelling of the labia
- D. Blood pressure 130/84 mm Hg
Correct Answer: B
Rationale: A fundus three fingerbreadths above the umbilicus indicates that the uterus is not adequately contracting, which can obstruct the flow of urine from the bladder. Postpartum clients often experience urinary retention due to decreased sensation in the bladder, trauma from delivery, and decreased bladder tone. Failure to empty the bladder promptly can lead to urinary retention and potential complications such as urinary tract infections or bladder distention. Therefore, the nurse should be alert to the client's need to urinate when assessing the fundal height.
Which factor should alert the nurse for the potential of a prolapsed umbilical cord?
- A. Presenting part at station minus 3 (too much empty space in between)
- B. Meconium stained amniotic fluid
- C. Pregnancy at 38 weeks' gestation
- D. Oligohydramnios
Correct Answer: A
Rationale: A presenting part at station minus 3 indicates that there is too much empty space between the presenting part (usually the fetus's head) and the pelvic inlet. This increased space raises the potential for the umbilical cord to prolapse through the cervix and into the birth canal ahead of the baby, especially when the membranes rupture. A prolapsed umbilical cord is a severe obstetric emergency that can cause fetal compromise due to umbilical cord compression and compromise of blood flow. It requires immediate intervention to relieve the pressure on the cord and increase the likelihood of a safe delivery. Therefore, a presenting part at station minus 3 should alert the nurse to the potential of a prolapsed umbilical cord.
A nurse is teaching a prenatal class regarding false labor. Which of the following information should the nurse include?
- A. "Your contraction will become more intense when walking"
- B. "You will have dilation and effacement of the cervix"
- C. You will have bloody show"
- D. "Your contraction will become temporally regular"
Correct Answer: D
Rationale: False labor, also known as Braxton Hicks contractions, are contractions that are irregular and do not lead to cervical dilation and effacement, unlike true labor contractions. During false labor, contractions may feel intense when walking, but they do not become progressively more intense over time, as is seen in true labor. Additionally, false labor contractions do not typically result in bloody show, which is a sign of impending true labor. Therefore, the correct information to include regarding false labor is that contractions will remain temporarily irregular in nature.
The nurse is performing Leopold's maneuvers. What is the primary goal?
- A. Determine fetal well-being.
- B. Assess fetal position and presentation.
- C. Measure amniotic fluid volume.
- D. Evaluate uterine contractions.
Correct Answer: B
Rationale: Leopold's maneuvers are used to assess fetal position, presentation, and engagement.
The best indication that correct attachment to the breast has occurred is when the:
- A. Baby's tongue is securely on top of the nipple.
- B. Baby's mouth covers most of the areolar surface
- C. Baby makes frequent loud clucking sounds while nursing at each breast d, Baby sucks each breast vigorously for five minutes before falling asleep
Correct Answer: B
Rationale: The best indication that correct attachment to the breast has occurred is when the baby's mouth covers most of the areolar surface. This is important because proper latch and attachment are crucial for effective breastfeeding. When the baby's mouth covers most of the areola, it ensures that the baby is latched onto the breast properly, allowing them to feed efficiently and receive an adequate amount of milk. This also helps prevent nipple soreness and pain for the mother. Additionally, when the baby's mouth covers most of the areola, it helps ensure that the baby is positioned correctly to effectively stimulate milk production and flow.