Question

A nurse is teaching a client and her partner about the technique of counter pressure during labor. Which of the following statements by the nurse is appropriate?

Answer 1

Correct Answers:

"Your partner will apply steady pressure with a tennis ball to your lower back.•

Rationale :

🎾 Counter-pressure is a nonpharmacologic pain relief method useful during back labor, often caused by fetal occiput posterior position.

🎾 Applying firm, steady pressure with a tennis ball or fist to the sacral area helps relieve pressure on the maternal spine.

🎾 The partner’s active role fosters support and comfort during labor.

🎾 Pressure techniques should always be guided by the laboring client’s feedback.

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Answer 2

Correct Answers:

Absent deep-tendon reflexes

Rationale :

🧠 Magnesium sulfate toxicity affects neuromuscular function, with loss of deep tendon reflexes (DTRs) being a critical early sign.

🧠 DTRs are usually assessed at the patella or Achilles tendon and should be checked hourly during administration.

🧠 Other concerning signs include respiratory depression and oliguria.

🧠 Prompt action (discontinuation and administration of calcium gluconate) is necessary if toxicity is suspected.

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Answer 3

Correct Answers:

The client has a fundal height of 38 cm

Rationale :

📏 At 32 weeks’ gestation, fundal height is expected to be around 30–34 cm. A height of 38 cm may indicate macrosomia or polyhydramnios, both linked to gestational diabetes.

📏 Further evaluation through ultrasound or blood glucose review is warranted.

📏 Edema, fetal movement, and glucose of 90 mg/dL are all within expected parameters.

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Answer 4

Correct Answers:

Third-degree perineal laceration

Rationale :

🚫 A third-degree laceration extends into the anal sphincter, and inserting a rectal suppository could traumatize the healing tissue.

🚫 Alternative stool softeners (e.g., docusate) should be used orally.

🚫 Conditions like abdominal distention or afterpains are not contraindications for suppository use.

🚫 Protecting the perineal area supports wound healing and comfort.

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Answer 5

Correct Answers:

Urine output 20 mL/hr

Rationale :

💧 Urine output <30 mL/hr indicates renal compromise, a key sign of magnesium sulfate accumulation and toxicity.

💧 Magnesium is excreted by the kidneys, so reduced clearance leads to dangerous levels.

💧 Respiratory rate of 16/min is within normal; hypertension and hyperglycemia are unrelated to magnesium.

💧 Monitoring I&O, reflexes, and respiratory status is essential.

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Answer 6

Correct Answers:

"l will drink water before the test until my bladder feels full."

Rationale :

🚰 A full bladder acts as an acoustic window for better ultrasound visualization of the uterus and fetus.

🚰 This applies especially to abdominal ultrasounds in the first and second trimesters.

🚰 Fasting, laxatives, or lotions are not needed before this non-invasive test.

🚰 Accurate prep enhances image quality and test efficiency.

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Answer 7

Correct Answers:

Turn the client onto their side.

Rationale :

🔄 Epidural anesthesia can cause vasodilation and hypotension by blocking sympathetic tone.

🔄 Turning the client to the left lateral position relieves vena cava compression and restores circulatory stability.

🔄 This is often the first step before administering fluids or medications.

🔄 Close monitoring of maternal BP and FHR is essential after epidural placement.

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Answer 8

Correct Answers:

Increased urination

Rationale :

🚽 Polyuria is a key sign of hyperglycemia due to osmotic diuresis.

🚽 The body attempts to excrete excess glucose via urine, leading to dehydration and electrolyte imbalance.

🚽 Sweating and dizziness are more indicative of hypoglycemia, while double vision occurs less frequently.

🚽 Early detection prevents ketoacidosis and fetal complications.

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Answer 9

Correct Answers:

An increase in fetal heart rate to 150/min above the baseline 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period

Rationale :

📊 A reactive NST requires at least 2 accelerations of 15 bpm above baseline for 15 seconds within 20 minutes.

📊 In this scenario, the increase lasts only 10 seconds, which is insufficient, and suggests a nonreactive NST.

📊 This necessitates additional fetal testing like a biophysical profile or CST.

📊 NST helps assess fetal oxygenation and CNS function.

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Answer 10

Correct Answers:

Midline episiotomy

Rationale :

🩹 A surgical incision such as an episiotomy creates a potential entry point for pathogens, increasing infection risk.

🩹 Proper perineal hygiene and monitoring for signs of redness, discharge, or swelling are crucial.

🩹 Other listed conditions (meconium-stained fluid, GH, placenta previa) are not direct contributors to postpartum infection.

🩹 Proactive care prevents endometritis and wound infection.

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QLexNursing

1 :
A nurse is teaching a client and her partner about the technique of counter pressure during labor. Which of the following statements by the nurse is appropriate?

2 :
A nurse is assessing a client who is at 32 weeks of gestation and is receiving magnesium sulfate via continuous IV infusion. Which of the following findings should the nurse report to the provider?

3 :
A nurse is caring for a client who is at 32 weeks of gestation and has gestational diabetes mellitus. Which of the following findings should the nurse report to the provider?

4 :
A nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery and reports constipation. Which of the following findings should the nurse identify as a contraindication to the use of a suppository?

5 :
A nurse is caring for a client who is at 30 weeks of gestation and receiving magnesium sulfate for preeclampsia. The nurse should recognize which of the following manifestations as an adverse reaction to the medication?

6 :
A nurse is providing teaching to a client who is primigravid and is scheduled to have an abdominal ultrasound. Which of the following statements by the client indicates an understanding of the teaching?

7 :
A nurse is caring for a client who is in labor and just received epidural anesthesia. The clientS blood pressure is 90/50 mm Hg. Which of the following actions should the nurse take?

8 :
A nurse is caring for a client who has pre-gestational diabetes mellitus. Which of the following clinical findings should indicate to the nurse the client has hyperglycemia?

9 :
A nurse is assessing the results of a no stress test for an antepartal client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing?

10 :
A nurse is reviewing the electronic medical record of a postpartum client. The nurse should identify which of the following factors places the client at risk for an infection?

QLexNursing

1 : A nurse is teaching a client and her partner about the technique of counter pressure during labor. Which of the following statements by the nurse is appropriate?

2 : A nurse is assessing a client who is at 32 weeks of gestation and is receiving magnesium sulfate via continuous IV infusion. Which of the following findings should the nurse report to the provider?

3 : A nurse is caring for a client who is at 32 weeks of gestation and has gestational diabetes mellitus. Which of the following findings should the nurse report to the provider?

4 : A nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery and reports constipation. Which of the following findings should the nurse identify as a contraindication to the use of a suppository?

5 : A nurse is caring for a client who is at 30 weeks of gestation and receiving magnesium sulfate for preeclampsia. The nurse should recognize which of the following manifestations as an adverse reaction to the medication?

6 : A nurse is providing teaching to a client who is primigravid and is scheduled to have an abdominal ultrasound. Which of the following statements by the client indicates an understanding of the teaching?

7 : A nurse is caring for a client who is in labor and just received epidural anesthesia. The clientS blood pressure is 90/50 mm Hg. Which of the following actions should the nurse take?

8 : A nurse is caring for a client who has pre-gestational diabetes mellitus. Which of the following clinical findings should indicate to the nurse the client has hyperglycemia?

9 : A nurse is assessing the results of a no stress test for an antepartal client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing?

10 : A nurse is reviewing the electronic medical record of a postpartum client. The nurse should identify which of the following factors places the client at risk for an infection?

1 :
A nurse is teaching a client and her partner about the technique of counter pressure during labor. Which of the following statements by the nurse is appropriate?

2 :
A nurse is assessing a client who is at 32 weeks of gestation and is receiving magnesium sulfate via continuous IV infusion. Which of the following findings should the nurse report to the provider?

3 :
A nurse is caring for a client who is at 32 weeks of gestation and has gestational diabetes mellitus. Which of the following findings should the nurse report to the provider?

4 :
A nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery and reports constipation. Which of the following findings should the nurse identify as a contraindication to the use of a suppository?

5 :
A nurse is caring for a client who is at 30 weeks of gestation and receiving magnesium sulfate for preeclampsia. The nurse should recognize which of the following manifestations as an adverse reaction to the medication?

6 :
A nurse is providing teaching to a client who is primigravid and is scheduled to have an abdominal ultrasound. Which of the following statements by the client indicates an understanding of the teaching?

7 :
A nurse is caring for a client who is in labor and just received epidural anesthesia. The clientS blood pressure is 90/50 mm Hg. Which of the following actions should the nurse take?

8 :
A nurse is caring for a client who has pre-gestational diabetes mellitus. Which of the following clinical findings should indicate to the nurse the client has hyperglycemia?

9 :
A nurse is assessing the results of a no stress test for an antepartal client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing?

10 :
A nurse is reviewing the electronic medical record of a postpartum client. The nurse should identify which of the following factors places the client at risk for an infection?