Nokea
Which advice can the nurse give to relieve the client's backache? Select all that apply.
- A. Avoid clothing that fits tightly around the waist.
- B. Sleep on a heating pad.
- C. Take a nonopioid pain reliever regularly.
- D. Wear low-heeled shoes.
- E. Carry objects close to your body.
- F. Squat when picking objects off the floor.
Correct Answer: A,D,E,F
Rationale: Tight clothing, high heels, and improper lifting exacerbate backaches; low-heeled shoes, proper lifting, and loose clothing help relieve strain.
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The nurse advises the client that this test is typically performed at what time during the pregnancy?
- A. Just after the pregnancy is confirmed
- B. Early in the second trimester
- C. In the transition phase of labor
- D. Just after the first fetal movements
Correct Answer: B
Rationale: Amniocentesis is typically performed early in the second trimester (15-20 weeks) to assess for genetic abnormalities.
The client is hospitalized at 30 weeks’ gestation in preterm labor. A test is performed to determine the lecithin to sphingomyelin (L/S) ratio, with results indicating a ratio less than 2:1. The nurse planning care for the client should expect to implement which interventions? Select all that apply.
- A. Administering hydralazine
- B. Maintaining the client on bedrest
- C. Preparing the client for a nonstress test
- D. Giving betamethasone
- E. Administering metronidazole
Correct Answer: B,C,D
Rationale: Bed rest will maximize placental oxygenation while fetal lung maturity continues. The client should be prepared for a nonstress test. This is used to monitor for uterine contractions and labor. Labor needs to be stopped until the fetal lungs are more fully developed. Betamethasone (Celestone Soluspan) is a corticosteroid and is given to stimulate fetal lung maturity. Hydralazine (Apresoline) is an antihypertensive agent and is administered to clients experiencing preeclampsia, not preterm labor. Metronidazole (Flagyl) is an antiprotozoal and antibacterial agent used to treat a vaginal infection; there is no indication that the client has a vaginal infection.
The nurse receives report for four postpartum clients. In which order should the nurse assess the clients? Prioritize the clients in order from first to last.
- A. The client who had a normal, spontaneous vaginal delivery 30 minutes ago.
- B. The client who had a cesarean section 48 hours ago and is bottle feeding her newborn infant.
- C. The client who had a vaginal delivery 32 hours ago and is having difficulty breastfeeding.
- D. The client who delivered her newborn via scheduled C-section 8 hours ago and has a PCA pump with morphine for pain control.
Correct Answer: A,D,C,B
Rationale: The client who had a normal, spontaneous vaginal delivery 30 minutes ago is priority. The first 2 hours after delivery is a time of transition, characterized by rapid changes in hemodynamic and physiological state for both the client and her newborn. The client who delivered her newborn via scheduled C-section 8 hours ago and has a PCA pump with morphine for pain control should be assessed next. Although she is 8 hours postpartum and probably stable, she is receiving morphine, and her respiratory status should be monitored Drag and Droply. The client who had a vaginal delivery 32 hours ago and is having difficulty breastfeeding should be assessed next. Newborn infants should successfully breastfeed every 2—3 hours. Failing to breastfeed with adequate amount and frequency may lead to newborn complications such as excessive weight loss and jaundice. The client who had a cesarean section 48 hours ago and is bottle feeding her newborn infant should be seen last; there is nothing indicating urgency.
The nurse correctly explains that the bleeding is the result of sloughing of which structure?
- A. Endometrium
- B. Myometrium
- C. Epimetrium
- D. None of the above
Correct Answer: A
Rationale: Menstrual bleeding occurs due to the sloughing of the endometrium, the inner lining of the uterus, when pregnancy does not occur.
Which client would the nurse identify as being at highest risk for developing complications during pregnancy?
- A. A 17-year-old gravida I client
- B. A client with the placenta implanted on the fundus of the uterus
- C. A client who has nausea and vomiting during the first trimester
- D. A 35-year-old gravida V client
Correct Answer: D
Rationale: A 35-year-old gravida V client is at higher risk due to advanced maternal age and multiple pregnancies, increasing complication risks.