Nokea
Which of the following would be the priority when the form of primigravid client whose exercise is dilated at 6 cm when the fetus is at 1+ station and the client has had no analgesia or anesthesia?
- A. Giving frequent sips of water.
- B. Applying extra blankets for warmth.
- C. Providing frequent perineal cleansing.
- D. Offering encouragement and support.
Correct Answer: D
Rationale: At 6 cm dilation without analgesia, the client is likely experiencing significant pain and anxiety. Offering encouragement and support is the priority to help her cope emotionally and physically. Hydration, warmth, and perineal cleansing are secondary concerns.
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A mother is visiting her neonate in the neonatal intensive care unit. Her baby is fussy and the mother wants to know what to do. In order to quiet a sick neonate, which of the following can the nurse teach the mother to do?
- A. Bring in toys for distraction.
- B. Place a musical mobile over the crib.
- C. Stroke the neonate's back.
- D. Use constant, gentle touch.
Correct Answer: D
Rationale: Constant, gentle touch is soothing and minimizes overstimulation for a sick neonate.
A primigravid client is admitted as an outpatient for an external cephalic version. The nurse should assess the client for which of the following contraindications for the procedure?
- A. Multiple gestation.
- B. Breech presentation.
- C. Maternal Rh-negative blood type.
- D. History of gestational diabetes.
Correct Answer: A
Rationale: External cephalic version (ECV) is contraindicated in multiple gestation due to the risk of cord entanglement or placental issues. Breech presentation is an indication for ECV, not a contraindication. Rh-negative blood type and gestational diabetes do not preclude ECV.
A nurse is counseling a client about the contraceptive sponge. Which of the following client statements indicates a need for further teaching?
- A. The sponge can be inserted just before intercourse.
- B. The sponge contains spermicide.
- C. The sponge is reusable if cleaned properly.
- D. The sponge should be left in place for at least 6 hours after intercourse.
Correct Answer: C
Rationale: The contraceptive sponge is a single-use device and cannot be reused, even if cleaned, indicating a need for further teaching. The other statements are correct.
A 32-year-old multigravida returns to the clinic for a routine prenatal visit at 36 weeks' gestation. She has had a prior pregnancy with pregnancy-induced hypertension. The assessments during this visit include BP 140/90, P 80, and +2 edema of the ankles and feet. Based on the client's past history and current assessment, what further information should the nurse obtain to determine if this client is becoming preeclamptic?
- A. Headaches.
- B. Blood glucose level.
- C. Proteinuria.
- D. Edema in lower extremities.
Correct Answer: C
Rationale: Proteinuria is a key indicator of preeclampsia, distinguishing it from gestational hypertension.
The nurse is receiving over the telephone a laboratory results report of a neonate's blood glucose level. The nurse should:
- A. Write the results in the chart, and receive confirmation from the caller that the nurse understands the results.
- B. Repeat the results to the caller from the laboratory, write the results on scrap paper first, and then transfer the results to the chart.
- C. Indicate to the caller that the nurse cannot receive verbal results from laboratory tests for neonates, and ask the laboratory to bring the written results to the nursery.
- D. Request that the laboratory send the results by email to transfer to the client's electronic record.
Correct Answer: A
Rationale: Writing the results and confirming with the caller ensures accuracy and compliance with documentation protocols.