Nokea
A client asks about the risks of the contraceptive injection. Which of the following would the nurse include?
- A. Increased risk of blood clots.
- B. Decreased bone density with long-term use.
- C. Permanent weight loss.
- D. Guaranteed regular periods.
Correct Answer: B
Rationale: The contraceptive injection may decrease bone density with long-term use, which is a significant risk. It does not significantly increase blood clot risk, cause permanent weight loss, or guarantee regular periods.
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Which of the following subjects should the nurse include when teaching the mother of a neonate diagnosed with retinopathy of prematurity (ROP) about possible treatment for complications?
- A. Laser therapy.
- B. Common medium (Intal) eye drops.
- C. Frequent testing for glaucoma.
- D. Corneal transplants.
Correct Answer: A
Rationale: Laser therapy is a common treatment for severe ROP to prevent retinal detachment.
The nurse has obtained a urine specimen from a G 6, P 5 client admitted to the labor unit. The woman asks to go to the bathroom and reports that she feels she has to move her bowels. Which actions would be appropriate? Select all that apply.
- A. Assisting her to the bathroom.
- B. Applying an external fetal monitor to obtain fetal heart rate.
- C. Assessing her stage of labor.
- D. Asking if she had back labor pains like this with any of her other deliveries.
- E. Allowing her support person to take her to the bathroom to maintain privacy.
- F. Checking the degree of fetal descent.
Correct Answer: C,F
Rationale: The urge to move bowels often indicates advanced labor or fetal descent in a multiparous client. Assessing the stage of labor and fetal descent (via vaginal exam) confirms progression and prevents unattended delivery. Assisting to the bathroom or relying on a support person risks delivery, and fetal monitoring or past labor history are secondary.
A primiparous client, who has just delivered a healthy term neonate after 12 hours of labor, holds and looks at her neonate and begins to cry. The nurse interprets this behavior as a sign of which of the following?
- A. Disappointment in the baby's gender.
- B. Grief over the ending of the pregnancy.
- C. A normal response to the birth.
- D. Indication of postpartum 'blues.'
Correct Answer: C
Rationale: Crying after delivery is a normal emotional response to the intense experience of birth, reflecting joy, relief, or overwhelming emotions. It does not indicate disappointment, grief, or postpartum blues, which typically manifest later.
After the nurse instructs a 20-year-old nulligravid client on how to perform a breast self-examination, which of the following client statements indicates that the teaching has been successful?
- A. I should perform breast self-examination on the day my menstrual flow begins.
- B. It's important that I perform breast self-examination on the same day each month.
- C. If I notice that one of my breasts is much smaller than the other, I shouldn't worry.
- D. If there is discharge from my nipples, I should call my health care provider.
Correct Answer: D
Rationale: Breast self-examination should be performed about a week after the menstrual period begins, when breasts are least tender. Noticing nipple discharge is a concerning symptom that warrants contacting a healthcare provider, indicating successful teaching.
The nurse is to assess a newborn for incurving of the trunk. Which illustration indicates the position in which the nurse should place the newborn?
Correct Answer: B
Rationale: To assess for incurving of the trunk, the newborn should be placed in a side-lying position to observe spinal curvature.