Nokea
A 39-year-old multigravid client asks the nurse for information about female sterilization with a tubal ligation. Which of the following client statements indicates effective teaching?
- A. My fallopian tubes will be tied off through a small abdominal incision.
- B. Reversal of a tubal ligation is easily done, with a subsequent pregnancy rate of 80%.
- C. The tubal ligation will decrease my risk of getting ovarian cancer.
- D. The tubal ligation will cause me to go through menopause earlier than usual.
Correct Answer: A
Rationale: Tubal ligation involves blocking or tying the fallopian tubes, often through a small abdominal incision. Reversal is complex with lower success rates, it does not significantly reduce ovarian cancer risk, and it does not affect menopause timing.
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A primiparous client who is bottle-feeding her neonate asks, "When should I start giving the baby solid foods?" The nurse instructs the client to introduce solid foods no sooner than at which age?
- A. 2 months.
- B. 6 months.
- C. 8 months.
- D. 10 months.
Correct Answer: B
Rationale: Solid foods are introduced around 6 months when the infant's digestive system is more mature.
A primiparous client 3 days postpartum is to be discharged on heparin therapy. After teaching her about possible adverse effects of heparin therapy, the nurse determines that the client needs further instruction when she states the adverse effects include which of the following?
- A. Epistaxis.
- B. Bleeding gums.
- C. Slow pulse.
- D. Petechiae.
Correct Answer: C
Rationale: Slow pulse is not a typical adverse effect of heparin; bleeding symptoms like epistaxis, bleeding gums, and petechiae are expected.
The nurse enlists the aid of an interpreter when caring for a primiparous client from Mexico who speaks very little English and delivered a viable term neonate 8 hours ago. When developing the postpartum dietary plan of care for the client, the nurse would encourage the client's intake of which of the following?
- A. High-fiber foods and adequate fluids.
- B. Low-calorie foods to promote weight loss.
- C. High-protein foods only.
- D. Caffeinated beverages to maintain energy.
Correct Answer: A
Rationale: High-fiber foods and adequate fluids promote bowel function and hydration, which are essential for postpartum recovery.
When reviewing the prenatal history for a newly delivered neonate, the nurse notes that the mother has neurofibromatosis. The nurse should further assess the neonate for:
- A. Caffé au lait spots.
- B. Port wine nevus.
- C. Strawberry hemangiomas.
Correct Answer: A
Rationale: Neurofibromatosis is associated with café au lait spots, which are a hallmark sign to assess in the neonate.
A client has admitted use of cocaine prior to beginning labor. After the infant is born, the nurse should anticipate the need to include which of the following actions in the infant's plan of care?
- A. Urine toxicology screening.
- B. Notifying hospital security.
- C. Limiting contact with visitors.
- D. Contacting local law enforcement.
Correct Answer: A
Rationale: Urine toxicology screening is necessary to assess for potential drug exposure in the newborn, which can affect their health and care plan.