Nokea
A client asks about the disadvantages of oral contraceptives. Which of the following would the nurse include?
- A. They must be taken at the same time daily for maximum effectiveness.
- B. They provide long-term contraception for up to 5 years.
- C. They are highly effective without side effects.
- D. They protect against STIs.
Correct Answer: A
Rationale: Oral contraceptives must be taken at the same time daily for maximum effectiveness, as timing affects hormone levels. They are short-term (daily), have potential side effects, and do not protect against STIs.
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A laboring client at -2 station has a spontaneous rupture of the membranes and a cord immediately protrudes from the vagina. The nurse should first:
- A. Place gentle pressure upward on the fetal head.
- B. Place the cord back into the vagina to keep it moist.
- C. Begin oxygen by face mask at 8 to 10 L/min.
- D. Turn the client on her left side.
Correct Answer: A
Rationale: Gentle pressure prevents cord compression.
After instructing a mother about normal reflexes of term neonates, the nurse determines that the mother understands the instructions when she describes the tonic neck reflex as occurring when the neonate does which of the following?
- A. Steps briskly when held upright near a firm, hard surface.
- B. Pulls both arms and does not move the chin beyond the point of the elbows.
- C. Turns head to the left, extends left extremities, and flexes right extremities.
- D. Extends and abducts the arms and legs with the toes fanning open.
Correct Answer: C
Rationale: The tonic neck reflex involves the neonate turning the head to one side, extending the extremities on that side, and flexing the opposite side.
Which of the following would lead the nurse to suspect retinopathy of prematurity (ROP) when assessing a neonate at 32 weeks' gestation who weighs 2,000 g ?
- A. Sunken orbital sockets.
- B. Strabismus.
- C. Reaction to bright light.
- D. Constricted retinal vessels.
Correct Answer: D
Rationale: Constricted retinal vessels are a sign of ROP, indicating abnormal retinal vascular development.
A primiparous client asks the nurse about resuming exercise after vaginal delivery. The nurse should advise the client to start low-impact exercises:
- A. Immediately after discharge.
- B. After 2 weeks postpartum.
- C. After 6 weeks postpartum.
- D. When lochia has completely stopped.
Correct Answer: C
Rationale: Low-impact exercises are generally safe after 6 weeks, allowing time for healing and recovery.
When teaching a primigravid client with diabetes about common causes of hyperglycemia during pregnancy, which of the following would the nurse include?
- A. Fetal macrosomia.
- B. Obesity before conception.
- C. Maternal infection.
- D. Pregnancy-induced hypertension.
Correct Answer: C
Rationale: Infection can cause hyperglycemia.