Nokea
Which client statement indicates a need for immediate intervention?
- A. I feel the baby move daily.
- B. I have mild swelling in my ankles.
- C. I haven't felt the baby move today.
- D. I'm eating a balanced diet.
Correct Answer: C
Rationale: A lack of fetal movement may indicate fetal distress, requiring immediate assessment and intervention.
You may also like to solve these questions
The client tells the nurse, “Most days, I am so happy I am pregnant, but other days, I am not sure that I am ready to have a baby.” Which is the most accurate response from the nurse?
- A. “This is such a happy time in your life. You need to be optimistic to feel happy.”
- B. “How does your spouse feel about the pregnancy? I hope he is happy about the baby.”
- C. “Feeling differently from day to day is normal. How do you feel today?”
- D. “Why do you feel this way? Is there something I can do to make it better for you?”
Correct Answer: C
Rationale: It is most therapeutic to acknowledge the client’s feelings and probe for more information on her thoughts and feelings about the pregnancy. Not all clients consider pregnancy a happy time in their lives, and the nurse should never tell the client how to feel. The nurse should not divert the client’s concerns away from self by bringing up the father’s adaptation to the pregnancy, even though paternal adaptation is related to maternal adaptation. The client may not be able to identify why she has the feelings she is experiencing or how the nurse can make her feel better. This response does not provide an avenue for further exploration of the client’s concerns.
The student nurse reports to an experienced nurse finding a warm, red, tender area on the left calf of the client who is 48 hours post—vaginal delivery. The nurse assesses the client and explains to the student that postpartum clients are at increased risk for thrombophlebitis due to which factors? Select all that apply.
- A. The fibrinogen levels in the blood of postpartum clients are elevated.
- B. Fluids normally shift from the interstitial to the intravascular space.
- C. Postpartum hormonal shifts irritate vascular basement membranes.
- D. Pressure is placed on the legs when elevated in stirrups during delivery.
- E. Dilation of veins in the lower extremities occurs during pregnancy.
- F. Compression of the common iliac vein occurs during pregnancy.
Correct Answer: A,D,E,F
Rationale: During pregnancy, fibrinogen levels increase, and this increase continues to be present in the postpartum period. The increased levels can contribute to clot formation. There is not a shift of fluid from the interstitial to the vascular spaces in the postpartum period. Actual blood volume increases during pregnancy and is further increased immediately after delivery. This fluid volume is eventually lost through diuresis during the first postpartum week. Postpartum hormonal changes do occur, but they do not affect the vascular basement membranes. Elevation of the legs in stirrups during delivery leads to pooling of blood and vascular stasis. Dilation of the veins in the lower extremities occurs during pregnancy and increases the risk of venous stasis. Compression of the common iliac vein occurs during pregnancy due to an enlarging fetus and increases the risk of venous stasis.
Which method best promotes client comfort during the pelvic examination?
- A. Have the client lift her head off the table.
- B. Have the client press her back into the examination table.
- C. Have the client tighten her buttocks.
- D. Tell the client to let her knees fall outward.
Correct Answer: D
Rationale: Letting the knees fall outward relaxes the pelvic muscles, reducing discomfort during the pelvic examination.
The experienced nurse is observing the new nurse determine the fetal position of the pregnant client using Leopold maneuver. The experienced nurse determines that the new nurse correctly identifies the first Leopold maneuver when placing the hands in which position illustrated first?
- A. Image A
- B. Image B
- C. Image C
- D. Image D
Correct Answer: B
Rationale: This illustration shows the first step of Leopold’s maneuver. The nurse palpates the fundus to determine which fetal body part (e.g., head or buttocks) occupies the uterine fundus. Image A shows the fourth Leopold maneuver. The nurse’s fingertips are used to determine the location of the cephalic prominence. Image C shows the third Leopold maneuver (“Pawlik maneuver”). During this maneuver the fetal part in the fundal region is compared with the part in the lower uterine segment. It is completed primarily to confirm that the fetus is in a cephalic (head) presentation. Image D shows the second Leopold maneuver. The second maneuver determines the location of the fetal back or spine.
The client expresses concerns related to nausea in the first trimester of pregnancy. Which recommendation should the nurse make?
- A. Eat crackers while still in bed in the morning.
- B. Lie down and rest whenever nausea occurs.
- C. Eat more frequently throughout the day.
- D. Avoid food items containing ginger.
Correct Answer: A
Rationale: The nurse should instruct the client to eat dry crackers before rising from bed. This typically relieves some of the nausea. Lying down when the nausea occurs may increase heartburn and reflux, thereby increasing nausea. Eating frequently may increase heartburn and reflux, thereby increasing nausea. Food items with ginger may help to alleviate nausea and are recommended (rather than avoided), including ginger tea.