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Two hours after vaginally delivering a viable male neonate under epidural anesthesia, the client with a midline episiotomy ambulates to the bathroom to void. After voiding, the nurse assesses the client's bladder, finding it distended. The nurse interprets this finding based on the understanding that the client's bladder distention is most likely caused by which of the following?
- A. Prolonged first stage of labor.
- B. Urinary tract infection.
- C. Pressure of the uterus on the bladder.
- D. Edema in the lower urinary tract area.
Correct Answer: D
Rationale: Edema in the lower urinary tract, often from delivery trauma or epidural anesthesia, can cause urinary retention and bladder distention.
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A multigravid client at 38 weeks' gestation, G4 P3, is 6 cm dilated with contractions every 3 minutes. The nurse observes meconium-stained amniotic fluid after spontaneous rupture of membranes. What is the priority nursing action?
- A. Prepare for immediate cesarean delivery.
- B. Assess the fetal heart rate pattern.
- C. Suction the client's oropharynx.
- D. Document the fluid characteristics.
Correct Answer: B
Rationale: Meconium-stained fluid raises the risk of fetal distress. Assessing the fetal heart rate pattern immediately ensures the fetus is tolerating labor. Cesarean delivery is not automatic, suctioning is irrelevant, and documentation follows assessment.
A multigravid client at 34 weeks' gestation with premature rupture of the membranes tests positive for group B streptococcus. The client is having contractions every 4 to 6 minutes. Her vital signs are as follows: blood pressure, 120/80 mm Hg; temperature, 100° F(37.8° C); pulse, 100 bpm; respirations, 18 breaths/minute. Which of the following would the nurse expect the physician to order?
- A. Intravenous penicillin.
- B. Intravenous gentamicin sulfate(Garamycin).
- C. Intramuscular betamethasone(Celestone).
- D. Intramuscular cefaclor(Ceclor).
Correct Answer: A
Rationale: Penicillin is used to treat group B streptococcus.
While assessing a primigravid client admitted at 36 weeks' gestation, the nurse observes multiple bruises on the client's face, neck, and abdomen. When asked about the bruises, the client admits that her boyfriend beats her now and then and says, 'I want to leave him because I'm afraid he will hurt the baby.' Which of the following actions is the nurse's priority?
- A. Tell the client to leave the boyfriend immediately.
- B. Ask the client when she last felt the baby move.
- C. Refer the client to a social worker for possible options.
- D. Report the incident to the unit nursing supervisor.
Correct Answer: C
Rationale: Suspected domestic violence requires referral to a social worker to provide resources (e.g., shelters, counseling) and ensure maternal-fetal safety. Advising immediate leaving is impractical, fetal movement assessment is secondary, and reporting to the supervisor does not directly help the client.
A multigravid client in active labor at 39 weeks' gestation has a history of smoking one to two packs of cigarettes daily. For which of the following should the nurse be alert when assessing the client's neonate?
- A. Hyperirritability.
- B. Hyperbilirubinemia.
- C. Low birth weight.
- D. Hypocalcemia.
Correct Answer: C
Rationale: Maternal smoking is strongly associated with low birth weight due to placental insufficiency and reduced fetal growth. Hyperirritability, hyperbilirubinemia, and hypocalcemia are less directly linked.
A nurse is counseling a client about the use of spermicides. Which of the following client statements indicates a need for further teaching?
- A. I should use spermicide with a condom for better protection.
- B. Spermicide should be applied 10-30 minutes before intercourse.
- C. Spermicide is effective for up to 24 hours after application.
- D. Spermicide may cause vaginal irritation in some users.
Correct Answer: C
Rationale: Spermicide is effective for about 1 hour after application, not 24 hours, indicating a need for further teaching. The other statements are correct.