Nokea
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.
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The nurse instructs the client to report which newborn symptom immediately?
- A. Mild jaundice on day 3
- B. Inability to suck or feed
- C. Occasional sneezing
- D. Soft spot on head
Correct Answer: B
Rationale: Inability to suck or feed is a serious symptom that may indicate neurological or health issues, requiring immediate reporting.
The nurse correctly assists the client into which position?
- A. Lithotomy
- B. Prone
- C. Sims'
- D. Trendelenburg's
Correct Answer: A
Rationale: The lithotomy position, with legs elevated and apart, is standard for pelvic examinations to provide access to the pelvic area.
The nurse is caring for the pregnant client. Which assessment findings help the nurse determine that she may be in true labor? Select all that apply.
- A. Progressive cervical dilation and effacement
- B. Walking usually increases contraction intensity
- C. Warm tub baths and rest lessen contractions
- D. Discomfort is usually in the client’s abdomen
- E. Contractions increase in duration and intensity
Correct Answer: A,B,E
Rationale: Progressive cervical dilation and effacement indicate true labor. In false labor, the contractions may occur for several hours, but there is no cervical change. In true labor, walking usually increases the intensity of contractions. In false labor, walking usually has little or no effect on contractions and may sometimes decrease the frequency, intensity, and duration of contractions. Contractions increase in duration and intensity during true labor, while there is usually no change in contractions during false labor. Warm tub baths and rest lessen contractions during false labor. In true labor, contractions do not decrease with warm tub baths or rest. Discomfort is usually in the client’s abdomen during false labor. Discomfort begins in the back and radiates around to the abdomen during true labor.
The client is diagnosed with moderate postpartum depression (PPD) after vaginal delivery of a 10 lb baby. One week following the delivery, the nurse is completing a home visit. Which finding should be the nurse’s priority?
- A. Lochia has a foul-smelling odor.
- B. Small but tender hemorrhoids.
- C. Yells at her baby to stop crying.
- D. Client cries throughout the visit.
Correct Answer: C
Rationale: Lochia that is foul smelling could indicate that the client has a postpartum infection. The client needs to be seen by an HCP, but the safety of the infant is priority. The presence of tender hemorrhoids may be uncomfortable and should be addressed, but this is not priority. It is inappropriate for the client to yell at her baby to stop crying. Verbal abuse can escalate to physical abuse. The safety of the infant should be the nurse’s priority. Persistent crying is a sign of PPD and would be expected. However, persistent crying should be further explored because treatment may be ineffective.
The postpartum client, who is 24 hours post—vaginal birth and breastfeeding, asks the nurse when she can begin exercising to regain her prepregnancy body shape. Which response by the nurse is correct?
- A. “Simple abdominal and pelvic exercises can begin right now.”
- B. “You will need to wait until after your 6-week postpartum checkup.”
- C. “Once your lochia has stopped, you can begin exercising.”
- D. “You should not exercise while you are breastfeeding.”
Correct Answer: A
Rationale: On the first postpartum day, the client should be taught to start abdominal breathing and pelvic rocking. Kegel exercises, which should have been taught during pregnancy, should be continued. Simple exercises should be added daily until, by 2 to 3 weeks postpartum, the mother should be able to do sit-ups and leg raises. Abdominal and pelvic exercises can begin right away and not wait for the 6-week postpartum checkup. There is no reason for the client to wait until the lochia has stopped before beginning exercises. There is no reason that a breastfeeding mother should not begin abdominal and pelvic exercises now.