Nokea
A client asks about the effectiveness of the contraceptive patch. Which of the following responses by the nurse is accurate?
- A. The patch is less effective than oral contraceptives.
- B. The patch is highly effective when used correctly.
- C. The patch is 100% effective in preventing pregnancy.
- D. The patch does not require a prescription.
Correct Answer: B
Rationale: The contraceptive patch is highly effective when used correctly, with a failure rate similar to oral contraceptives (about 1% with perfect use). It is not 100% effective, requires a prescription, and is not less effective than pills.
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A 30-year-old woman, G 4, P 4, has delivered a healthy term female neonate by cesarean delivery due to a nonreassuring fetal heart rate tracing. At 2 hours postpartum, the nurse assesses the client's retention catheter and observes that the client's urine is slightly red tinged. Which of the following should the nurse do next?
- A. Continue to monitor the client's input and output.
- B. Massage the client's fundus gently every 15 minutes.
- C. Assess the placement of the retention catheter.
- D. Contact the client's physician for further orders.
Correct Answer: C
Rationale: Red-tinged urine may indicate catheter trauma or misplacement, requiring assessment of catheter placement.
After explaining to a primiparous client about the causes of her neonate's cranial molding, which of the following statements by the mother indicates the need for further instruction?
- A. The molding was caused by an overlapping of the baby's cranial bones during my labor.'
- B. The amount of molding is related to the amount and length of pressure on the head.'
- C. The molding will usually disappear in a couple of days.'
- D. Brain damage may occur if the molding doesn't resolve quickly.'
Correct Answer: D
Rationale: Cranial molding is a normal process that resolves within days and does not cause brain damage, indicating the mother needs further instruction.
The nurse is receiving over the telephone a laboratory results report of a neonate's blood glucose level. The nurse should:
- A. Write the results in the chart, and receive confirmation from the caller that the nurse understands the results.
- B. Repeat the results to the caller from the laboratory, write the results on scrap paper first, and then transfer the results to the chart.
- C. Indicate to the caller that the nurse cannot receive verbal results from laboratory tests for neonates, and ask the laboratory to bring the written results to the nursery.
- D. Request that the laboratory send the results by email to transfer to the client's electronic record.
Correct Answer: A
Rationale: Writing the results and confirming with the caller ensures accuracy and compliance with documentation protocols.
The nurse is assessing the perineal changes of a multigravid client in the second stage of labor. The illustration below represents which of the following perineal changes?
- A. Anterior-posterior slit.
- B. Oval opening.
- C. Circular shape.
- D. Crowning.
Correct Answer: D
Rationale: If the illustration shows the fetal head visible at the perineum with no retraction between contractions, and the perineal area appears bulging or stretched, this indicates crowning — the point at which birth is imminent.
The nurse on a mother-baby unit who is working on the night shift is revising the planning worksheet for the remaining 2 hours of the shift. The nurse has the following tasks and orders to complete prior to the 7 a.m. change of shift. Using the work plan below, how should the nurse organize the following tasks so that everything is completed by 7 a.m.?
- A. Draw blood for the ordered laboratory tests (CBCs) on 3 postpartum clients with report on charts by shift change.
- B. Start IV of D5 1/2 NS at keep vein open (KVO) rate on postpartum client just prior to change of shift.
- C. Complete admission assessment of newborn turned over to nurse at 5 a.m.
- D. Draw newborn bilirubin level at 6 a.m.
Correct Answer: A,C,D,B
Rationale: 5:00 - Complete admission assessment; 5:30 - Draw CBCs; 6:00 - Draw bilirubin; 6:30 - Start IV. This ensures timely completion.