Nokea
A 21-year-old primigravid client at 40 weeks' gestation is admitted to the hospital in active labor. The client's cervix is 8 cm and completely effaced at 0 station. During the transition phase of labor, which of the following is a priority nursing diagnosis?
- A. Impaired urinary elimination related to nothing-by-mouth status.
- B. Risk for injury related to hyperventilation and dizziness.
- C. Ineffective coping related to lack of confidence.
- D. Pain related to increasing frequency and intensity of uterine contractions.
Correct Answer: D
Rationale: During the transition phase (8–10 cm), intense and frequent contractions cause significant pain, making pain management the priority nursing diagnosis. Urinary elimination issues are less urgent, hyperventilation is a secondary concern, and coping issues are not as immediate as pain.
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A client asks about the effectiveness of male condoms. Which of the following responses by the nurse is accurate?
- A. They are 100% effective in preventing pregnancy.
- B. They are highly effective when used correctly.
- C. They require a prescription.
- D. They are less effective than the withdrawal method.
Correct Answer: B
Rationale: Male condoms are highly effective when used correctly, with a low failure rate. They are not 100% effective, do not require a prescription, and are more effective than the withdrawal method.
A neonate delivered at 30 weeks' gestation and weighing $2,000 \mathrm{~g}$ is admitted to the neonatal intensive care unit. What nursing measure will decrease insensible water loss in a neonate?
- A. Bathing the baby as soon after birth as possible.
- B. Use of eye patches with phototherapy.
- C. Use of humidity in the incubator.
- D. Use of a radiant warmer.
Correct Answer: C
Rationale: Using humidity in the incubator helps maintain a moist environment, reducing insensible water loss through the skin, which is critical for preterm neonates with immature skin barriers.
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.
Several pregnant clients are waiting to be seen in the triage area of the obstetrical unit. Which client should the nurse see first?
- A. A client at 13 weeks' gestation experiencing nausea and vomiting three times a day with +1 ketones in her urine.
- B. A client at 37 weeks' gestation who is an insulin-dependent diabetic and experiencing 3 to 4 fetal movements per day.
- C. A client at 32 weeks' gestation who has preeclampsia and +3 proteinuria who is returning for evaluation of epigastric pain.
- D. A primigravida at 17 weeks' gestation complaining of not feeling fetal movement at this point in her pregnancy.
Correct Answer: C
Rationale: Epigastric pain in a preeclamptic client can indicate impending eclampsia.
A client is considering the copper IUD. Which of the following statements by the nurse is accurate?
- A. It requires replacement every 6 months.
- B. It is hormone-free and effective for up to 10 years.
- C. It reduces menstrual bleeding.
- D. It prevents ovulation.
Correct Answer: B
Rationale: The copper IUD is hormone-free and effective for up to 10 years. It does not require replacement every 6 months, may increase menstrual bleeding, and does not prevent ovulation.