Nokea
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.
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The RN and the student nurse are caring for the postpartum client who is 16 hours postdelivery. The RN evaluates that the student needs more education about uterine assessment when the student is observed doing which activity?
- A. Elevating the client’s head 30 degrees before doing the assessment
- B. Supporting the lower uterine segment during the assessment
- C. Gently palpating the uterine fundus for firmness and location
- D. Observing the abdomen before beginning palpation
Correct Answer: A
Rationale: For uterine assessment, the client should be positioned in a supine position so the height of the uterus is not influenced by an elevated position. When beginning the assessment, one hand should be placed at the base of the uterus just above the symphysis pubis to support the lower uterine segment. This prevents the inadvertent inversion of the uterus during palpation. Once the lower hand is in place, the fundus of the uterus can be gently palpated. The abdomen should be observed prior to palpation for contour to detect distention and for the appearance of striae or a diastasis.
When the client asks why folic acid is important, which response by the nurse is most accurate?
- A. Folic acid helps prevent neural tube defects such as spina bifida.
- B. Folic acid helps build strong bones for your baby.
- C. Folic acid helps your baby become resistant to infections.
- D. Folic acid prevents your baby from becoming anemic.
Correct Answer: A
Rationale: Folic acid is critical for preventing neural tube defects like spina bifida by supporting early fetal development.
The nurse assesses the pregnant client who comes to the triage unit and determines that she is at 4/50/—1 and that the fetal HR is 148. What priority information should the nurse collect before proceeding?
- A. Time and amount of last meal
- B. Number of weeks’ gestation
- C. Who is attending the delivery
- D. History of previous illnesses
Correct Answer: B
Rationale: Knowing the weeks of gestation is most important because if she is in premature labor, she may need to be given tocolytics to stop the process and to ensure adequate fetal lung maturity. If she is full term, the labor process could continue. The time and amount of last meal is important to know, but number of weeks’ gestation is more important. This client is dilated at 4 cm and in active labor. Who will attend the delivery should be identified during admission to the labor unit, but it is not the most important when being evaluated in triage. History of previous illnesses should be collected during admission to the labor unit, but it is not the most important when being evaluated in triage.
Immediately after delivery of the client’s placenta, the nurse palpates the client’s uterine fundus. The fundus is firm and located halfway between the umbilicus and symphysis pubis. Which action should the nurse take based on the assessment findings?
- A. Immediately begin to massage the uterus
- B. Document the findings of the fundus
- C. Assess the client for bladder distention
- D. Monitor for increased vaginal bleeding
Correct Answer: B
Rationale: Uterine massage is indicated only if the uterus does not feel firm and contracted. Immediately after birth, the uterus should contract, and the fundus should be located one-half to two-thirds of the way between the symphysis pubis and umbilicus. Thus the only action required is to document the assessment finding. There is no indication that the bladder is full. A full bladder will cause uterine displacement to either side of the abdomen. The uterus is firm; there is no reason to infer that increased vaginal bleeding would occur.
The nurse asks the 12-hour postpartum client, who is breastfeeding her baby now, why she has not yet received a dinner tray. The client states that her mother is bringing curry and that she won’t be eating the hospital food tonight. Which response by the nurse is best?
- A. “Please let me know if you change your mind. I can order food for you later.”
- B. “Since you are breastfeeding, you should avoid eating highly spiced food.”
- C. “I will ask the dietitian to meet with you so you can discuss your nutritional needs.”
- D. “You should not be eating highly spiced food 12 hours after delivery.”
Correct Answer: A
Rationale: Offering to order food later if the client changes her mind is the best response. Many clients have culturally based beliefs about food and beverages that should be consumed in the postpartum period. Unless contraindicated, nurses should support and encourage women to incorporate food preferences with cultural significance into their postpartum diet. Some breastfeeding infants are sensitive to certain flavors, seasonings, or foods, but, there is no evidence to support maternal food restrictions unless the infant shows a sensitivity. If there is a strong family history of a food allergy that causes anaphylaxis, such as a peanut allergy, these foods may be avoided. Many women would benefit from speaking to a dietician, but this client is not at any increased risk that would make a dietary consultation necessary. There are no food restrictions 12 hours after delivery unless there have been complications.