Nokea
Two days after hospital discharge, the nurse is assessing the mother and her newborn twins in their home. Which statement or question made by the nurse best demonstrates empathy?
- A. “You may be feeling overwhelmed. This is normal.”
- B. “I can’t imagine how tired you must be with twins.”
- C. “How are you feeling about being the mother of twins?”
- D. “I saw that laundry is piling up. Do you want a home aide?”
Correct Answer: C
Rationale: Projecting feelings onto the client does not demonstrate empathy. This statement imposes a personal assumption and does not demonstrate empathy. This question demonstrates empathy. The nurse is asking a question to allow the client to explain her situation and feelings while the nurse listens. The nurse is attempting to understand the experience as lived by the client. Acknowledging that laundry is piling up and offering home aide services do not demonstrate empathy. Commenting on the laundry on the first visit may suggest to the client that she lacks support, and she may be defensive or hurt by the acknowledgement.
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The postpartum client suffered a fourth-degree perineal laceration during her vaginal birth. Which interventions should the nurse add to the client’s plan of care? Select all that apply.
- A. Limit ambulation to bathroom privileges only.
- B. Decrease fluid intake to 1000 mL every 24 hours.
- C. Instruct the client on a high-fiber diet.
- D. Monitor the uterus for firmness every 2 hours.
- E. Give pm prescribed stool softeners in the am. and at h.s.
Correct Answer: C,E
Rationale: Activity should be increased, not decreased, to reduce the potential for constipation. Fluids should be increased, not decreased, to reduce the potential for dehydration and constipation. The client with a fourth-degree perineal laceration should be instructed to increase dietary fiber to help maintain bowel continence and decrease perineal trauma from constipation. A perineal laceration will not affect the condition of the uterus; there is no need to increase uterine monitoring. The client with a fourth-degree perineal laceration should be given a stool softener bid to help maintain bowel continence and decrease perineal trauma from constipation.
The nurse correctly explains that fertilization usually takes place in which structure?
- A. Fallopian tube
- B. Ovary
- C. Uterus
- D. Vagina
Correct Answer: A
Rationale: Fertilization typically occurs in the fallopian tube, where the sperm meets the ovum after ovulation.
The nurse is counseling the client who is trying to become pregnant. To promote fetal health when the client is unaware of a pregnancy, the nurse should stress the inclusion of which nutrient in daily food intake?
- A. Potassium
- B. Calcium
- C. Folic acid
- D. Sodium
Correct Answer: C
Rationale: The nurse should educate the client about the need for adequate folic acid intake. Folic acid is important in preventing neural tube defects, especially during the first four weeks of fetal development. Potassium is important in preventing leg cramps during pregnancy, but this is usually not an issue during the first four weeks of gestation. Calcium is important for fetal development of bones, teeth, heart, nerves, and muscles, but the fetus will take calcium from the mother. Calcium is more important to maternal health than fetal development. Sodium is important for maintaining optimal electrolyte balance but is typically ingested in more than adequate amounts in a typical diet.
The nurse is caring for the client who has been in the second stage of labor for the last 12 hours. The nurse should monitor for which cardiovascular change that occurs during this stage of labor?
- A. An increase in maternal heart rate
- B. A decrease in the cardiac output
- C. An increase in the white blood cell (WBC) count
- D. A decreased intravascular volume during contractions
Correct Answer: A
Rationale: Maternal HR is normally increased due to pain resulting from increased catecholamine secretion, fear, anxiety, and increased blood volume. When the laboring client holds her breath and pushes against a closed glottis, intrathoracic pressure rises. Blood in the lungs is forced into the left atrium, leading to a transient increase (not decrease) in cardiac output. Although the WBCS increase to 25,000/mm3 to 30,000/mm3 during labor and early postpartum as a physiological response to stress, this is not a cardiovascular change. During the second stage of labor, the maternal intravascular volume is increased (not decreased) by 300 to 500 mL of blood from the contracting uterus.
The nurse, admitting a 40-week primigravida to the labor unit, just documented the results of a recent vaginal exam: 3/100/—2, RSP. How should the oncoming shift nurse interpret this documentation?
- A. The fetus is approximately 2 cm below maternal ischial spines.
- B. The cervix is totally dilated and effaced, with fetal engagement.
- C. The fetus is breech and posterior to the client’s pelvis.
- D. The fetal lie is transverse, and the fetal attitude is flexion.
Correct Answer: C
Rationale: The nurse should interpret 3/100/—2, RSP as the cervix is 3 cm dilated, 100% effaced, and the fetus is 2 cm above the maternal ischial spines. RSP means that the fetus is to the right of the mother’s pelvis (R), with the sacrum as the specific presenting part (S), which is a breech position. This fetus is also posterior (P). At —2, the fetus is 2 cm above, not below, the maternal ischial spines. Two centimeters below the ischial spines would be recorded as +2. The cervix is 3 cm, not totally dilated. Total dilation would be documented as 10 for the first number. Also, the cervix is 100% effaced, which is total effacement (shortening and thinning out). Fetal lie (relationship of long axis or spine of fetus to long axis of mother) is longitudinal, not transverse. The documentation does not specify if the fetal attitude is flexion.