Nokea
Two hours after delivery the nurse assesses the client and documents that the fundus is soft, boggy, above the level of the umbilicus, and displaced to the right side. The nurse encourages the client to void. Which is the rationale for this nursing action?
- A. A full bladder prevents normal contractions of the uterus.
- B. An overdistended bladder may press against the episiotomy causing dehiscence.
- C. Distention of the bladder can cause urinary stasis and infection.
- D. It makes the client more comfortable when the fundus is massaged.
Correct Answer: A
Rationale: The correct answer is A: A full bladder prevents normal contractions of the uterus. A full bladder can impede the involution process of the uterus by exerting pressure on it, inhibiting proper contraction. This can lead to postpartum hemorrhage and increased risk of retained placental fragments. Encouraging the client to void helps to relieve the pressure on the uterus, allowing it to contract effectively and aiding in the expulsion of lochia and prevention of complications.
Other choices are incorrect because:
B: An overdistended bladder may press against the episiotomy causing dehiscence - While this is a potential risk, it is not directly related to fundal assessment and contraction.
C: Distention of the bladder can cause urinary stasis and infection - While true, this is not the primary concern when assessing the fundus post-delivery.
D: It makes the client more comfortable when the fundus is massaged - Massaging the fundus is a separate intervention and does
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A client who is 37 weeks gestation comes to the office for a routine visit. This is the client's first baby and she asks the nurse how she will know when labor begins. Which signs indicate that true labor has begun?
- A. Contractions that are irregular and decrease in intensity when walking
- B. Abdominal pain that starts at the fundus and progresses to the lower back
- C. Increased pressure on the bladder and urinary frequency
- D. Expulsion of pink-tinged mucous and contractions that start in the lower back
Correct Answer: D
Rationale: The correct answer is D because the expulsion of pink-tinged mucous (bloody show) and contractions starting in the lower back are indicative of true labor. This is due to the release of the mucus plug and the initiation of true uterine contractions. Contractions that start in the lower back and progress to the front are characteristic of true labor.
Choice A is incorrect because contractions that are irregular and decrease in intensity with walking are characteristic of false labor (Braxton Hicks contractions).
Choice B is incorrect as abdominal pain starting at the fundus and progressing to the lower back is not a specific sign of true labor.
Choice C is incorrect as increased pressure on the bladder and urinary frequency are common throughout pregnancy and not specific to the onset of true labor.
In summary, the correct answer D provides specific and characteristic signs of true labor, while the other choices do not accurately reflect the onset of true labor.
A client, gravida 1, para 0, in active labor, is becoming increasingly anxious. Which statement by the nurse will block therapeutic communication with the client?
- A. What concerns are you having now?
- B. Tell me how you are feeling.
- C. Everything is going just fine.
- D. You seem a little nervous.
Correct Answer: C
Rationale: Correct Answer: C
Rationale:
1. Choice A and B encourage the client to express their concerns and feelings, promoting therapeutic communication.
2. Choice D acknowledges the client's emotions, showing empathy and understanding.
3. Choice C dismisses the client's anxiety, invalidating their feelings, hindering communication.
Summary:
Choices A, B, and D promote open communication and empathy, while choice C ignores the client's anxiety, making it the incorrect choice.
A woman in active labor receives a narcotic analgesic for pain control. If the narcotic is given a half an hour before delivery, which effect will the medication have on the infant?
- A. It will cause the infant's blood sugar to fall.
- B. It will cause the infant's respiratory rate to decrease.
- C. It will cause the infant's heart rate to increase.
- D. It will cause the infant's movements to be hyperactive.
Correct Answer: B
Rationale: The correct answer is B: It will cause the infant's respiratory rate to decrease. Narcotic analgesics can cross the placenta and affect the baby. These medications can depress the respiratory drive of the newborn, leading to decreased respiratory rate. This effect is particularly pronounced if the narcotic is given shortly before delivery when the drug levels in the infant's system are highest. The other choices are incorrect because: A) Narcotics are not known to directly affect blood sugar levels in infants. C) Narcotics typically cause a decrease, rather than an increase, in heart rate. D) Narcotics are more likely to cause sedation and decreased movements rather than hyperactivity in newborns.
In a child diagnosed with Tetralogy of Fallot, which of the following is a compensatory mechanism to decrease venous return to the heart?
- A. Squatting
- B. Clubbing
- C. Shortness of breath
- D. Polycythemia
Correct Answer: A
Rationale: Squatting is a compensatory mechanism that decreases venous return (deoxygenated blood) to the heart. This clinical sign is commonly seen in young children with Tetralogy of Fallot, a type of cyanotic heart disease. Squatting helps reduce the workload on the heart by decreasing the amount of deoxygenated blood returning to it.
A woman in the first trimester comes to the clinic with vaginal bleeding. The physician determines that the fetus has died and that the placenta, fetus, and tissues still remain in the uterus. How should the findings be documented?
- A. Complete abortion
- B. Stillborn abortion
- C. Missed abortion
- D. Incomplete abortion
Correct Answer: C
Rationale: The correct answer is C: Missed abortion. In a missed abortion, the fetus has died but has not been expelled from the uterus yet. The findings should be documented as a missed abortion because the fetus has not been passed naturally. This is different from a complete abortion (A) where all products of conception have been expelled, a stillborn abortion (B) which is not a recognized medical term, and an incomplete abortion (D) where some products of conception remain in the uterus. Therefore, based on the scenario described, the most appropriate term to document the findings is missed abortion.