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 nurse teaches the client to report which postpartum symptom immediately?
- A. Mild cramping
- B. Foul-smelling lochia
- C. Light vaginal bleeding
- D. Fatigue after delivery
Correct Answer: B
Rationale: Foul-smelling lochia may indicate infection, requiring immediate reporting to prevent complications.
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.
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.
The nurse is teaching the postpartum client, who is breastfeeding, about returning to sexual activity after vaginal delivery. Which statement should the nurse include?
- A. “Orgasm may decrease the amount of breast milk you produce.”
- B. “You may need to use lubrication when resuming sexual intercourse.”
- C. “You should not have sexual intercourse until two months postpartum.”
- D. “Your HCP will let you know when you can resume sexual activity.”
Correct Answer: B
Rationale: Oxytocin is released when the client has an orgasm and may cause breast milk to leak or squirt from the breasts. The production of breast milk may increase, not decrease. The nurse should inform the client that she may need lubrication with sexual intercourse because the low estrogen levels in the early postpartum period causes vaginal dryness. Women should refrain from sexual intercourse until lochia has ceased, which usually takes about 3 weeks. There is no need to wait two months if the lochia has ceased. The client’s HCP does not need to give approval to return to sexual activity.
Which nursing instructions concerning exercise during pregnancy are accurate? Select all that apply.
- A. Avoid exercising during hot, humid weather.
- B. Avoid exercises involving bouncing or jumping movements.
- C. Drink plenty of fluids before and after exercising.
- D. Limit strenuous activity to no more than 60 minutes a session.
- E. Perform exercises only in the supine position.
- F. Limit exercising to once per week.
Correct Answer: A,B,C
Rationale: Exercising in hot weather risks overheating, bouncing movements may strain joints, and hydration is crucial. Supine exercises are avoided late in pregnancy.