Nokea
While assessing the fundus of a multiparous client 36 hours after delivery of a term neonate, the nurse notes a separation of the abdominal muscles. The nurse should tell the client:
- A. She will have a surgical repair at 6 weeks postpartum.
- B. To remain on bed rest until resolution occurs.
- C. The separation will resolve on its own with the right posture and diet.
- D. To perform exercises involving head and shoulder raising in a lying position.
Correct Answer: D
Rationale: Diastasis recti often resolves with specific exercises like head and shoulder raises, which strengthen abdominal muscles.
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A nurse is teaching a client about the use of the contraceptive injection. Which of the following client statements indicates a need for further teaching?
- A. I will need an injection every 3 months.
- B. The injection may cause irregular bleeding.
- C. The injection is reversible, but fertility may take time to return.
- D. The injection will protect me from STIs.
Correct Answer: D
Rationale: The contraceptive injection does not protect against STIs, indicating a need for further teaching. The other statements are correct regarding frequency, side effects, and reversibility.
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.
A primigravid client at 37 weeks' gestation has been hospitalized for several days with severe pregnancy-induced hypertension. While caring for the client, the nurse observes that the client is beginning to have a seizure. Which of the following actions should the nurse do first?
- A. Pad the side rails of the client's bed.
- B. Turn the client to the right side.
- C. Insert a padded tongue blade into the client's mouth.
- D. Call for immediate assistance in the client's room.
Correct Answer: D
Rationale: A seizure in pregnancy-induced hypertension (eclampsia) is a medical emergency. Calling for immediate assistance ensures rapid intervention (e.g., magnesium sulfate). Padding rails, repositioning, or inserting a tongue blade (which is outdated) are secondary.
The nurse is assessing fetal presentation in a multiparous client. The illustration below indicates which of the following types of presentation?
- A. Frank breech.
- B. Complete breech.
- C. Footling breech.
- D. Vertex.
Correct Answer: D
Rationale: Without the illustration, the context suggests a typical presentation for a multiparous client, which is most likely vertex (head-down), the most common and favorable for vaginal delivery.
A multiparous client at 24 hours postpartum demonstrates a positive Homan's sign with discomfort. The nurse should:
- A. Place a cold pack on the client's perineal area.
- B. Place the client in a semi-Fowler's position.
- C. Notify the client's physician immediately.
- D. Ask the client to ambulate around the room.
Correct Answer: C
Rationale: A positive Homan's sign suggests possible deep vein thrombosis, requiring immediate physician notification.