Nokea
A breast-feeding primiparous client who delivered 8 hours ago asks the nurse, "How will I know that my baby is getting enough to eat?" Which of the following guidelines should the nurse include in the teaching plan as evidence of adequate intake?
- A. Six to eight wet diapers by the fifth day.
- B. Three to four transitional stools on the fourth day.
- C. Ability to fall asleep easily after feeding on the first day.
- D. Regain of lost birth weight by the third day.
Correct Answer: A
Rationale: Six to eight wet diapers by the fifth day indicate adequate milk intake.
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A client is considering the contraceptive patch. Which of the following instructions should the nurse provide?
- A. Apply a new patch daily for three weeks, then skip a week.
- B. Change the patch weekly for three weeks, then have a patch-free week.
- C. Wear the patch for one month, then replace it.
- D. Apply the patch to the genital area for best results.
Correct Answer: B
Rationale: The contraceptive patch is changed weekly for three weeks, followed by a patch-free week to allow for a withdrawal bleed. It is not applied daily, worn for a month, or placed on the genital area.
A client has obtained Plan B (levonorgestrel 0.75 mg, 2 tablets) as emergency contraception. After unprotected intercourse, the client calls the clinic to ask questions about taking the contraceptives. The nurse realizes the client needs further explanation when she makes which of the following responses?
- A. I can wait 3 to 4 days after intercourse to start taking these to prevent pregnancy.
- B. My boyfriend can buy Plan B from the pharmacy if he is over 18 years old.
- C. The birth control works by preventing ovulation or fertilization of the egg.
- D. I can be discussed and have breast tenderness or a headache after using the contraceptive.
Correct Answer: A
Rationale: Plan B is most effective when taken within 72 hours of unprotected intercourse, ideally as soon as possible. Waiting 3 to 4 days reduces its efficacy, indicating a need for further explanation.
A multiparous client delivers dizygotic twins at 37 weeks' gestation. The twin neonates require additional hospitalization after the client is discharged. In planning the family's care, an appropriate goal for the nurse to formulate is that, while the twins are hospitalized, the parents will do which of the following?
- A. Discuss how they will cope with twin infants at home.
- B. Participate in care of the twins as much as possible.
- C. Take turns providing 24-hour observation of the twins.
- D. Identify complications that may occur as the twins develop.
Correct Answer: B
Rationale: Parental participation in twin care during hospitalization promotes bonding, confidence, and skill development. Discussing coping, 24-hour observation, or identifying complications are less immediate or unrealistic.
After the delivery of a neonate, a quick assessment is completed. The neonate is found to be apneic. After quickly drying the neonate, what should the nurse do next?
- A. Assign the first Apgar score.
- B. Place the head in a 'sniff' position.
- C. Administer oxygen.
- D. Start cardiac compressions.
Correct Answer: B
Rationale: Placing the head in a 'sniff' position opens the airway, which is critical for an apneic neonate before further interventions.
A nurse is counseling a client about the contraceptive sponge. Which of the following instructions should the nurse include?
- A. Insert the sponge at least 1 hour before intercourse.
- B. Leave the sponge in place for at least 6 hours after intercourse.
- C. Reuse the sponge if it is undamaged.
- D. Apply spermicide to the sponge after insertion.
Correct Answer: B
Rationale: The contraceptive sponge should be left in place for at least 6 hours after intercourse to ensure effectiveness. It should be inserted just before intercourse, cannot be reused, and contains spermicide, so additional application is not needed.