Nokea
While a client is being admitted to the birthing unit she states, 'My water broke last night, but my labor started two hours ago.' Which of the following is a concern? Select all that apply.
- A. Maternal lacerations.
- B. 130/80 mm Hg.
- C. Blood and mucus on perineal pad.
- D. Baseline fetal heart rate of 140 with a range between 110 and 160 with contractions.
- E. Peripad stained with green fluid.
- F. The client states, 'This baby wants out-he keeps kicking me.'
Correct Answer: E
Rationale: Prolonged rupture of membranes (>18 hours) increases infection risk, and green fluid suggests meconium, indicating potential fetal distress. Normal blood pressure, bloody show, fetal heart rate variability, and fetal movement are not immediate concerns.
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A client is considering the contraceptive injection. Which of the following client statements indicates understanding?
- A. The injection is given every 3 months.
- B. The injection protects against STIs.
- C. The injection requires daily administration.
- D. The injection causes permanent infertility.
Correct Answer: A
Rationale: The contraceptive injection is given every 3 months, providing sustained contraception. It does not protect against STIs, is not taken daily, and does not cause permanent infertility.
A nurse is discussing the copper IUD with a client. Which of the following client statements indicates understanding?
- A. The copper IUD is effective for up to 10 years.
- B. The copper IUD prevents ovulation.
- C. The copper IUD reduces menstrual bleeding.
- D. The copper IUD requires daily insertion.
Correct Answer: A
Rationale: The copper IUD is effective for up to 10 years, providing long-term contraception. It does not prevent ovulation, may increase menstrual bleeding, and does not require daily insertion.
Two hours after vaginally delivering a viable male neonate under epidural anesthesia, the client with a midline episiotomy ambulates to the bathroom to void. After voiding, the nurse assesses the client's bladder, finding it distended. The nurse interprets this finding based on the understanding that the client's bladder distention is most likely caused by which of the following?
- A. Prolonged first stage of labor.
- B. Urinary tract infection.
- C. Pressure of the uterus on the bladder.
- D. Edema in the lower urinary tract area.
Correct Answer: D
Rationale: Edema in the lower urinary tract, often from delivery trauma or epidural anesthesia, can cause urinary retention and bladder distention.
Which of the following would the nurse include in the teaching plan for a primiparous client about the frequency of breast-feeding the neonate during the first few days?
- A. Feeding the neonate whenever he or she cries.
- B. Restricting feedings to 1 to 2 minutes per side.
- C. Feeding the neonate for at least 10 minutes per side.
- D. Maintaining feeding for 20 to 30 minutes per side.
Correct Answer: C
Rationale: Feeding for at least 10 minutes per side ensures adequate milk transfer and stimulation of milk production.
A primiparous client who delivered a viable neonate 8 hours ago tells the nurse that she gained 26 lb during pregnancy and asks how long it will take to return to her normal prepregnant weight. The nurse should tell the client that the usual time frame for returning to prepregnant weight is:
- A. 4 weeks.
- B. 6 weeks.
- C. 8 weeks.
- D. 12 weeks.
Correct Answer: D
Rationale: Returning to prepregnant weight typically takes about 12 weeks with proper diet and exercise.