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While caring for a multiparous client 4 hours after vaginal delivery of a term neonate, the nurse notes that the mother's temperature is 99.8°F (37.2°C), the pulse is 66 bpm, and the respirations are 18 breaths/minute. Her fundus is firm, midline, and at the level of the umbilicus. The nurse should:
- A. Continue to monitor the client's vital signs.
- B. Assess the client's lochia for large clots.
- C. Notify the client's physician about the findings.
- D. Offer the mother an ice pack for her forehead.
Correct Answer: A
Rationale: A slightly elevated temperature (99.8°F) within the first 24 hours is normal; continued monitoring is appropriate with otherwise normal findings.
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A client is induced with oxytocin (Pitocin). The fetal heart rate is showing accelerations lasting 15 seconds and exceeding the baseline with fetal movement. What action associated with this finding should the nurse take?
- A. Turn the client to her left side.
- B. Administer oxygen via facemask at 10 to 12 L/minute.
- C. Notify the health care provider of the situation.
- D. Document fetal well-being.
Correct Answer: D
Rationale: Fetal heart rate accelerations with movement indicate fetal well-being, requiring no intervention beyond documentation. Repositioning, oxygen, or notification are unnecessary.
A primigravid client with severe preeclampsia exhibits hyperactive, very brisk patellar reflexes with two beats of ankle clonus present. The nurse documents the patellar reflexes as which of the following?
- A. 1+.
- B. 2+.
- C. 3+.
- D. 4+.
Correct Answer: C
Rationale: Hyperactive reflexes are documented as 3+.
A nurse is counseling a client about the vaginal contraceptive ring. Which of the following client statements indicates a need for further teaching?
- A. I will leave the ring in place for three weeks.
- B. I may experience nausea or breast tenderness.
- C. I can remove the ring for up to 3 hours if needed.
- D. The ring will make my periods heavier.
Correct Answer: D
Rationale: The vaginal contraceptive ring typically reduces menstrual flow or causes lighter periods, not heavier ones. The other statements are correct, indicating a need for further teaching about menstrual effects.
A 30-year-old multigravid client at 8 weeks' gestation has a history of insulin-dependent diabetes since age 20. When explaining about the importance of blood glucose control during pregnancy, the nurse should tell the client that which of the following will occur regarding the client's insulin needs during the first trimester?
- A. They will increase.
- B. They will decrease.
- C. They will remain constant.
- D. They will be unpredictable.
Correct Answer: B
Rationale: Insulin needs typically decrease in the first trimester due to increased insulin sensitivity.
An adolescent primiparous client 24 hours postpartum asks the nurse how often she should hold her neonate. Which of the following responses would be most appropriate?
- A. Hold him when he is fussy or crying.
- B. Hold him as much as you want to hold him.
- C. Try to hold him infrequently to avoid overstimulation.
- D. You can hold him periodically throughout the day.
Correct Answer: B
Rationale: Holding the neonate as much as desired promotes bonding and emotional security without risk of overstimulation.