Nokea
When developing the plan of care for a multigravid client with class III heart disease, which of the following areas should the nurse expect to assess frequently?
- A. Dehydration.
- B. Nausea and vomiting.
- C. Iron-deficiency anemia.
- D. Tachycardia.
Correct Answer: D
Rationale: Class III heart disease indicates significant cardiac limitation, making tachycardia a critical sign of cardiac stress during labor. Frequent assessment ensures early detection of decompensation. Dehydration, nausea, or anemia are less immediate concerns.
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A primigravid client whose cervix is 7 cm dilated with the fetus at 0 station and in a left occipitoposterior (LOP) position requests pain relief for severe back pain. The nurse should:
- A. Provide firm pressure to the client's sacral area.
- B. Prepare the client for a cesarean delivery.
- C. Prepare the client for a precipitate delivery.
- D. Place the client in a left side-lying position.
Correct Answer: A
Rationale: LOP position often causes severe back pain due to the fetal occiput pressing against the sacrum. Firm sacral pressure (counterpressure) can alleviate this pain. Cesarean or precipitate delivery is not indicated unless other complications arise, and side-lying may help but is less specific.
A 24-year-old client is discussing contraception options with the nurse and expresses interest in an intrauterine device (IUD). Which of the following statements by the client indicates a need for further teaching?
- A. I understand the IUD can remain in place for several years.
- B. The IUD will prevent ovulation each month.
- C. I may experience heavier menstrual periods with the copper IUD.
- D. The IUD does not protect against sexually transmitted infections.
Correct Answer: B
Rationale: The IUD does not primarily prevent ovulation; it works by affecting sperm movement and preventing fertilization (copper IUD) or thinning the uterine lining (hormonal IUD). The other statements are correct, indicating a need for further teaching about its mechanism.
Two weeks after a breast-feeding primiparous client is discharged, she calls the birthing center and says that she is afraid she is "losing my breast milk. The baby had been nursing every 4 hours, but now she's crying to be fed every 2 hours." The nurse interprets the neonate's behavior as most likely caused by which of the following?
- A. Lack of adequate intake to meet maternal nutritional needs.
- B. The mother's fears about the baby's weight gain.
- C. Preventing the neonate from sucking long enough with each feeding.
- D. The neonate's temporary growth spurt, which requires more feedings.
Correct Answer: D
Rationale: Increased feeding frequency at 2 weeks is typical of a growth spurt, requiring more frequent nursing.
After teaching the multiparous mother about hemolytic disease of the newborn and Rh sensitization, the nurse determines that the client understands why she was not sensitized during her other pregnancy when she says which of the following?
- A. My other baby had a different father.'
- B. Like most women, I have immunity against the Rh factor.'
- C. Antibodies are not usually formed until after exposure to an antigen.'
- D. My blood couldn't neutralize antibodies formed from my first pregnancy.'
Correct Answer: C
Rationale: Antibodies form after exposure to an Rh-positive fetus, typically not during the first pregnancy, explaining why sensitization did not occur previously.
While the nurse is assessing the fundus of a multiparous client who delivered 24 hours ago, the client asks, "What can I do to get rid of these stretch marks?" Which of the following responses would be most appropriate?
- A. As long as you don't get pregnant again, the marks will disappear completely.
- B. They usually fade to a silvery-white color over a period of time.
- C. You'll need to use a specially prescribed cream to help them disappear.
- D. If you lose the weight you gained during pregnancy, the marks will fade to a pale pink.
Correct Answer: B
Rationale: Stretch marks typically fade to a silvery-white color over time without specific intervention.