Nokea
A client asks about the disadvantages of the contraceptive sponge. Which of the following would the nurse include?
- A. It is difficult to insert and remove.
- B. It provides protection against STIs.
- C. It can be left in place for up to 48 hours.
- D. It is highly effective for women who have given birth.
Correct Answer: A
Rationale: The contraceptive sponge can be difficult to insert and remove, especially for some users. It does not protect against STIs, can be left in place for up to 24 hours (not 48), and is less effective for women who have given birth due to changes in vaginal anatomy.
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The physician determines that the fetus of a multiparous client in active labor is in distress, necessitating a cesarean delivery with general anesthesia. Before the cesarean delivery, the anesthesiologist orders cimetidine (Tagamet) 300 mg PO. After administering the drug, the nurse should assess the client for reduction in which of the following?
- A. Incidence of bronchospasm.
- B. Oral and respiratory secretions.
- C. Acid level of the stomach contents.
- D. Incidence of postoperative gastric ulcer.
Correct Answer: C
Rationale: Cimetidine, an H2-receptor blocker, is given before general anesthesia to reduce gastric acid levels, minimizing the risk of aspiration pneumonitis. It does not affect bronchospasm, secretions, or postoperative ulcers directly.
A client asks about the benefits of male condoms. Which of the following would the nurse include?
- A. They are 100% effective in preventing pregnancy.
- B. They provide some protection against STIs.
- C. They can be reused if undamaged.
- D. They require a prescription.
Correct Answer: B
Rationale: Male condoms provide some protection against STIs, which is a key benefit. They are not 100% effective, cannot be reused, and do not require a prescription.
A nurse is counseling a client about the vaginal contraceptive ring. Which of the following client statements indicates a need for further teaching?
- A. I will leave the ring in place for three weeks.
- B. I may experience nausea or breast tenderness.
- C. I can remove the ring for up to 3 hours if needed.
- D. The ring will make my periods heavier.
Correct Answer: D
Rationale: The vaginal contraceptive ring typically reduces menstrual flow or causes lighter periods, not heavier ones. The other statements are correct, indicating a need for further teaching about menstrual effects.
For the client who is receiving intravenous magnesium sulfate for severe preeclampsia, which of the following assessment findings would alert the nurse to suspect hypermagnesemia?
- A. Decreased deep tendon reflexes.
- B. Cool skin temperature.
- C. Rapid pulse rate.
- D. Tingling in the toes.
Correct Answer: A
Rationale: Decreased deep tendon reflexes are a sign of hypermagnesemia.
Two hours ago, a multigravid client was admitted in active labor with her cervix dilated at 5 cm and completely effaced and the fetus at 0 station. Currently, the client is experiencing nausea and vomiting, a slight chill with perspiration beads on her lip, and extreme irritability. The nurse should first:
- A. Warm the temperature of the room by a few degrees.
- B. Increase the rate of intravenous fluid administration.
- C. Obtain an order for an intramuscular antiemetic medication.
- D. Assess the client's cervical dilation and station.
Correct Answer: D
Rationale: Nausea, chills, perspiration, and irritability are signs of the transition phase (8–10 cm dilation). Assessing cervical dilation and station confirms progression and guides care. Warming the room, increasing fluids, or administering antiemetics are secondary.