Nokea
Using Naegele's Rule, the nurse can assume the client's expected delivery date to be approximately which date?
- A. 13-Nov
- B. 23-Nov
- C. 3-Dec
- D. 20-Dec
Correct Answer: C
Rationale: Naegele's Rule: Subtract 3 months from the first day of the last menstrual period (March 13) and add 7 days, resulting in December 3.
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The laboring client suddenly experiences a dramatic drop in the FHR from the 150s to the 110s. A vaginal exam reveals the presence of the fetal cord protruding through the cervix. What should be the nurse’s first intervention?
- A. Put continuous pressure on the presenting part to keep it off the cord
- B. Place the bed in Trendelenburg position
- C. Insert a urinary catheter and instill saline
- D. Continue to monitor the FHR
Correct Answer: A
Rationale: The nurse should first exert continuous pressure on the presenting part to prevent further cord compression. This is continued until birth, which is usually by cesarean section. The bed should be placed in Trendelenburg position to further prevent pressure on the cord, but only after pressure is placed on the presenting part. A catheter may be inserted and 500 mL of warmed saline instilled to help float the head and prevent further compression, but only after pressure is placed on the presenting part. The fetus is continually monitored throughout until birth.
Which statement made by a participant indicates the need for additional teaching regarding management of urinary frequency?
- A. Limiting fluid intake will help control this problem.
- B. I should report a burning sensation during urination.
- C. Urinating before going to bed may help control this problem.
- D. Avoiding caffeinated beverages may help control the problem.
Correct Answer: A
Rationale: Limiting fluid intake is not recommended, as hydration is essential; the other statements reflect appropriate management strategies.
The laboring client in the first stage of labor is talking and laughing with her husband. The nurse should conclude that the client is probably in what phase?
- A. Transition
- B. Active
- C. Active pushing
- D. Latent
Correct Answer: D
Rationale: During the latent phase (1—3 cm), the client is usually happy and talkative. During the transition phase (8—10 cm), the client is usually more restless, irritable, and more likely to lose control. During the active phase (4—7 cm), the client may become more anxious and fatigued and needs to concentrate on breathing techniques to cope with the increasingly stronger contractions. The client who is actively pushing is focusing on how effective she is in the descent of the fetus and concentrating on how she is coping with contractions. She is usually not expressing happiness or laughter, and is not talkative.
Which newborn behavior is normal and does not require immediate concern?
- A. Frequent hiccups
- B. Persistent vomiting
- C. Lethargy for days
- D. High fever
Correct Answer: A
Rationale: Frequent hiccups are normal in newborns and typically resolve without intervention, unlike the other symptoms.
The pregnant client tells the nurse that she smokes two packs per day (PPD) of cigarettes, has smoked in other pregnancies, and has never had any problems. What is the nurse’s best response?
- A. “I’m glad that your other pregnancies went well. Smoking can cause both maternal and fetal problems, and it is best if you could quit smoking.”
- B. “You need to stop smoking for the baby’s sake. You could have a spontaneous abortion with this pregnancy if you continue to smoke.”
- C. “Smoking can lead to having a large baby, which can make delivery difficult. You may even need a cesarean section.”
- D. “Smoking less would eliminate the risk for your baby, and you would feel healthier during your pregnancy.”
Correct Answer: A
Rationale: The nurse is acknowledging that the client did not experience problems with her other pregnancies but is also informing the client that smoking can cause maternal and fetal problems during pregnancy. Telling the client to stop smoking for the baby’s sake is confrontational, making the client less likely to listen to the nurse’s teaching. Although spontaneous abortion is associated with tobacco use during pregnancy, the nurse is using a scare tactic rather than therapeutic communication. Smoking can lead to a fetus that is small for gestational age, not a large baby. Decreasing her smoking intake should be suggested; however, it does not eliminate the risk to the baby completely.