A client asks about the side effects of the contraceptive implant. Which of the following would the nurse include?
- A. Regular menstrual cycles are guaranteed.
- B. Irregular bleeding is a common side effect.
- C. It causes significant weight loss.
- D. It increases the risk of ovarian cysts.
Correct Answer: B
Rationale: Irregular bleeding is a common side effect of the contraceptive implant, especially in the first year. It does not guarantee regular cycles, cause significant weight loss, or significantly increase ovarian cyst risk.
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Which of the following would alert the nurse to suspect that a neonate delivered at 34 weeks' gestation who is currently in an isolette with humidified oxygen and receiving intravenous fluids has developed overhydration?
- A. Hypernatremia.
- B. Polycythemia.
- C. Hypoproteinemia.
- D. Increased urine specific gravity.
Correct Answer: C
Rationale: Hypoproteinemia can result from overhydration, as excess fluid dilutes plasma proteins.
At which of the following locations would the nurse expect to palpate the fundus of a primiparous client immediately after delivery of a neonate?
- A. Halfway between the umbilicus and the symphysis.
- B. At the level of the umbilicus.
- C. Just below the level of the umbilicus.
- D. Above the level of the umbilicus.
Correct Answer: B
Rationale: Immediately after delivery, the fundus is typically at the level of the umbilicus due to the uterus beginning to involute.
The father of a neonate diagnosed with gastroschisis tells the nurse that his wife had planned on breast-feeding the neonate. Which of the following should the nurse include in the preoperative teaching plan about feeding the neonate?
- A. The neonate will remain on nothing-by-mouth (NPO) status until after surgery.
- B. An iron-fortified formula will be given before surgery.
- C. The neonate will need total parenteral nutrition for nourishment.
- D. The mother may breast-feed the neonate before surgery.
Correct Answer: A
Rationale: The neonate must remain NPO before surgery to prevent complications related to the exposed intestines.
The physician who elects to perform a cesarean delivery on a primigravid client for fetal distress has informed the client of possible risks during the procedure. When the nurse asks the client to sign the consent form, the client's husband says, 'I'll sign it for her. She's too upset by what is happening to make this decision.' The nurse should:
- A. Ask the client if this is acceptable to her.
- B. Have the client and her husband both sign the consent form.
- C. Ask the client to sign the consent form.
- D. Ask the doctor to witness the consent form.
Correct Answer: C
Rationale: The client must provide informed consent unless incapacitated. The nurse should ask the client to sign, ensuring she understands despite her distress. The husband cannot sign unless legally authorized, and dual signatures or physician witnessing are unnecessary.
After instruction of a primigravid client at 8 weeks' gestation about measures to overcome early morning nausea and vomiting, which of the following client statements indicates the need for additional teaching?
- A. "I'll eat dry crackers or toast before arising in the morning."
- B. "I'll drink adequate fluids separate from my meals or snacks."
- C. "I'll eat two large meals daily with frequent protein snacks."
- D. "I'll snack on a small amount of carbohydrates throughout the day."
Correct Answer: C
Rationale: Two large meals may worsen nausea; smaller, more frequent meals are recommended.
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