Nokea
Which of the following would alert the nurse to suspect that a neonate delivered at 34 weeks' gestation who is currently in an isolette with humidified oxygen and receiving intravenous fluids has developed overhydration?
- A. Hypernatremia.
- B. Polycythemia.
- C. Hypoproteinemia.
- D. Increased urine specific gravity.
Correct Answer: C
Rationale: Hypoproteinemia can result from overhydration, as excess fluid dilutes plasma proteins.
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The nurse is caring for a primigravid client in active labor at 42 weeks' gestation. The client has had no analgesia or anesthesia and has been pushing for 2 hours. The nurse can be most helpful to this client by:
- A. Changing her pushing position every 15 minutes.
- B. Notifying the health care provider of her current status.
- C. Continuing with current pushing technique.
- D. Assessing the client's current pain and fetal status.
Correct Answer: D
Rationale: Prolonged pushing (2 hours) in a primigravid client at 42 weeks requires assessment of pain and fetal status to identify potential complications like exhaustion or fetal distress. Changing positions may help but is less urgent, notifying the provider is premature without assessment, and continuing the current technique may not address underlying issues.
The nurse is teaching a group of women about fertility awareness methods of contraception. Which of the following would the nurse include as the most reliable indicator that ovulation has occurred?
- A. A slight drop followed by a rise in basal body temperature.
- B. A change in cervical mucus to thin, clear, and stretchy.
- C. The onset of mittelschmerz, or midcycle pelvic pain.
- D. The presence of a thick, cloudy cervical mucus.
Correct Answer: A
Rationale: A slight drop followed by a rise in basal body temperature is the most reliable indicator of ovulation, as it reflects the hormonal shift post-ovulation. Cervical mucus changes and mittelschmerz are less precise, and thick mucus typically occurs post-ovulation.
A client is considering permanent contraception. Which of the following client statements indicates a need for further teaching?
- A. Tubal ligation is considered permanent.
- B. Vasectomy requires a follow-up sperm count.
- C. Tubal ligation will cause early menopause.
- D. Both procedures require general anesthesia.
Correct Answer: C
Rationale: Tubal ligation does not cause early menopause, as it only blocks the fallopian tubes and does not affect ovarian hormone production. The other statements are correct, though anesthesia type may vary.
While the nurse is caring for a primiparous client with cephalopelvic disproportion 4 hours after a cesarean delivery, the client requests assistance in breast-feeding. To promote maximum maternal comfort, which of the following would be most appropriate for the nurse to suggest?
- A. Football hold.
- B. Scissors hold.
- C. Cross-cradle hold.
- D. Cradle hold.
Correct Answer: A
Rationale: The football hold minimizes pressure on the cesarean incision, promoting comfort during breastfeeding.
The nurse is explaining the medication options available for pain relief during labor. The nurse realizes the client needs further teaching when the client states which of the following?
- A. Nubain (nalbuphine) and Phenergan (promethazine) will give relief from pain and nausea during early labor.'
- B. I can have an epidural as soon as I start contracting.'
- C. If I have a cesarean, I can have an epidural.'
- D. If I have an emergency cesarean, I may be put to sleep for the delivery.'
Correct Answer: B
Rationale: Epidurals are typically administered in active labor (e.g., 4–5 cm dilation), not immediately upon contracting, indicating a need for further teaching. The other statements are accurate regarding pain relief options.