Nokea
What instruction is most important for the nurse to provide a client in the first trimester of pregnancy who is experiencing nausea?
- A. Avoid alcohol, caffeine, and smoking.
- B. Eliminate between meal snacks
- C. Practice relaxation techniques when the nausea first begins
- D. Increase intake of fluids to 3 quarts daily
Correct Answer: C
Rationale: Relaxation techniques like deep breathing can help manage nausea, especially if triggered by stress or anxiety, making it the most effective immediate intervention.
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The nurse examines a client who is admitted in active labor and determines the cervix is 3 cm dilated 50% effaced, and the presenting part is at 0 station. An hour later. she tells the nurse that she wants to go to the bathroom. Which action should the nurse implement first?
- A. Review the fetal heart rate pattern
- B. Check the pH of the vaginal fluid
- C. Determine cervical dilation.
- D. Palpate the client's bladder
Correct Answer: D
Rationale: A desire to use the bathroom may indicate a full bladder, which can impede labor progress. Palpating the bladder is the priority to assess this.
The nurse is caring for a client who delivered 6 hours ago. Assessment findings reveal a boggy uterus that is displaced above and to the right of the umbilicus. Which action should the nurse take?
- A. Encourage voiding
- B. Notify healthcare provider
- C. Inspect the perineal pad
- D. Monitor vital signs
Correct Answer: A
Rationale: A boggy uterus displaced above and to the right of the umbilicus often indicates a distended bladder, which can prevent proper uterine contraction. Encouraging voiding addresses this issue, helping the uterus return to its normal position and firm up.
A client who delivered vaginally 2 days ago states that she wants to resume using her diaphragm for birth control. What information should the nurse share with her?
- A. The diaphragm must be refitted after childbirth
- B. The most effective form of contraception is a diaphragm
- C. The diaphragm should be inserted 2 to 4 hours before intercourse.
- D. Vaseline lubricant can be used when inserting the diaphragm
Correct Answer: A
Rationale: Childbirth can alter vaginal and cervical anatomy, requiring the diaphragm to be refitted for effective contraception.
The nurse is assessing a newborn who was precipitously delivered at 38-weeks gestation The newborn is tremulous, tachycardic, and hypertensive. Which assessment action is most important for the nurse to implement?
- A. Obtain a drug screen for cocaine
- B. Weigh and measure the newborn
- C. Determine reactivity of neonatal reflexes
- D. Perform gestational age assessment
Correct Answer: A
Rationale: Tremulousness, tachycardia, and hypertension in a newborn suggest possible drug exposure, such as cocaine, requiring an urgent drug screen to guide treatment.
A new mother who is breastfeeding her 4-week-old infant and has type 1 diabetes, reports that her insulin needs have decreased since the birth of her child. Which action should the nurse implement?
- A. Schedule an appointment for the client with the diabetic nurse educator.
- B. Counsel her to increase her caloric intake
- C. Inform her that a decreased need for insulin occurs while breastfeeding
- D. Advise the client to breastfeed more frequently
Correct Answer: C
Rationale: Breastfeeding can lower insulin requirements due to increased energy expenditure, and informing the client of this normal change is appropriate.