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When up to the bathroom for the first time after a vaginal delivery, the client states, “A friend told me that I’m going to have trouble with urinary incontinence now that I have had a baby.” Which is the best response by the nurse?
- A. “That’s not true. You won’t need to worry about this until menopause.”
- B. “I will teach you how to do Kegel exercises to strengthen your muscles.”
- C. “Wearing a pad similar to a sanitary pad will help contain the incontinence.”
- D. “If this occurs, notify your HCP to have surgery to correct urinary incontinence.”
Correct Answer: B
Rationale: Women of any life stage can experience urinary incontinence. Kegel exercises strengthen muscles surrounding the vagina and urinary meatus, preventing urinary incontinence for many women. To perform Kegel exercise, contract the muscles around the vagina and hold for 10 seconds, then rest for 10 seconds. This should be repeated 30 or more times each day. The nurse should educate the client about ways in which to prevent urinary incontinence, not just offer information about how to manage the condition if it should occur. Surgical repair only occurs in the most extreme circumstances, after less invasive interventions have been unsuccessful.
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A 5-minute-old newborn in a delivery room has a good cry, HR 88, well flexed, good reflex irritability, and blue extremities with a completely pink body. What Apgar score would the nurse document for this newborn?
Correct Answer: 8
Rationale: The newborn would receive one point because the HR is below 100 bpm, two points for a good cry (respiratory effort), two points for being well flexed (muscle tone), two points for good reflex irritability (reflex response), and one point for a pink body with blue extremities (color).
Twenty-four hours after the birth of her first child, the 25-year-old single client tells the nurse that she has several different male sex partners and asks the nurse to recommend an appropriate birth control method for her. Considering her lifestyle, which method of birth control should the nurse suggest?
- A. An intrauterine device (IUD)
- B. Depot-medroxyprogesterone acetate injections
- C. A female condom with nonoxynol-9
- D. A diaphragm
Correct Answer: C
Rationale: IUDs offer no protection against STIs. They are recommended for women who are in a stable, mutually monogamous relationship. Depot-medroxyprogesterone acetate (Depo-Provera) is a long-acting progestin that is highly effective for birth control. A single injection will provide contraception for 3 months but does not offer protection against STIs. A female condom does provide protection against some of the pathogens that cause STIs, and it would be readily available over the counter. A diaphragm offers no protection against STIs.
The clinic nurse reviews the laboratory results illustrated from the postpartum client who is 3 days postdelivery. What should the nurse do in response to these results?
- A. Document the laboratory report findings
- B. Assess the client for increased lochia
- C. Assess the client’s temperature orally
- D. Notify the health care provider immediately
Correct Answer: A
Rationale: The only action required is to document the findings; all values are within expected parameters. Nonpathological leukocytosis often occurs during labor and in the immediate postpartum period because labor produces a mild pro-inflammatory state. WBCs should return to normal by the end of the first postpartum week. Hct and Hgb will begin to decrease on postpartum day 3 or 4 from hemodilution. Assessing the client’s lochia is unnecessary with these results. Assessing the client’s temperature is unnecessary with these results. Notifying the HCP is unnecessary with these results.
The nurse is reviewing the laboratory report from the first prenatal visit of the pregnant client. Which laboratory result should the nurse most definitely discuss with the HCP?
- A. Hemoglobin 11 g/dL; hematocrit 33%
- B. White blood cell (WBC) count: 7000/mm3
- C. Pap smear: human papilloma virus changes
- D. Urine pH: 7.4; specific gravity 1.015
Correct Answer: C
Rationale: A Pap smear with HPV changes reflects an abnormal result. HPV changes are a risk factor for cervical cancer. The nurse should discuss the result with the HCP because it requires further assessment and follow-up. A normal Hgb is 12—15 g/dL; nutritional counseling should be initiated when the Hgb is less than 12 g/dL. An Hct of 33% is also low (normal Hct value = 38% to 47%; this decreases by 4% to 7% in pregnancy), but increasing the Hgb with iron-rich foods should also raise the Hct. A WBC count of 7000/mm3 is within the normal range of 5000 to 12,000/mm3. A urine pH of 7.4 is within the normal range of 4.6 to 8.0; the specific gravity is within the normal range of 1.010 to 1.025.
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.