A client asks about the side effects of the vaginal contraceptive ring. Which of the following would the nurse include?
- A. Nausea and breast tenderness may occur.
- B. It causes permanent infertility.
- C. It requires surgical insertion.
- D. It guarantees regular periods.
Correct Answer: A
Rationale: Nausea and breast tenderness are possible side effects of the vaginal contraceptive ring, especially initially. It does not cause permanent infertility, require surgical insertion, or guarantee regular periods.
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The nurse is planning care for a group of pregnant clients. Which of the following clients should be referred to a health care provider immediately?
- A. A woman who is at 10 weeks' gestation, is having nausea and vomiting, and has +1 ketones in her urine.
- B. A woman who is at 37 weeks' gestation and has insulin-dependent diabetes experiencing 2-3 hyperglycemic episodes weekly.
- C. A woman at 32 weeks' gestation and is preeclamptic with +3 proteinuria.
- D. A primigravida at 15 weeks' gestation who reports she is not feeling fetal movement.
Correct Answer: C
Rationale: Severe preeclampsia requires immediate attention.
A nurse is discussing preterm labor in a prenatal class. After class, a client and her partner ask the nurse to identify again the nursing strategies to prevent preterm labor. The clients need further instruction when they state which of the following?
- A. "I need to stay hydrated all the time."
- B. "I need to avoid any infections."
- C. "I should include frequent rest breaks if we travel."
- D. "Changing to filter cigarettes is helpful."
Correct Answer: D
Rationale: Smoking, even with filter cigarettes, is harmful and should be avoided.
Assessment of a 23-year-old primigravid client at term who is admitted to the birthing unit in active labor reveals that her cervix is 4 cm dilated and 100% effaced. Contractions are occurring every 4 minutes. The nurse is developing a care plan with the client to relieve pain based on the gate-control theory of pain. The nurse should explain which of the following to the client?
- A. Input from the large sensory fibers opens the gate.
- B. Labor pain is a matter of individual perception.
- C. Slow abdominal breathing can open the gate.
- D. The gating mechanism is in the spinal cord.
Correct Answer: D
Rationale: The gate-control theory posits that pain signals are modulated in the spinal cord, where non-painful stimuli (e.g., touch) can 'close the gate' to pain transmission. Input from large fibers closes the gate, perception varies but is not the mechanism, and slow breathing helps manage pain but does not open the gate.
A 24-year-old primigravid client who delivers a viable term neonate is ordered to receive the primary effect of the placenta. Which of the following signs would indicate to the nurse that the placenta is about to be delivered?
- A. The cord lengthens outside the vagina.
- B. There is decreased vaginal bleeding.
- C. The uterus cannot be palpated.
- D. Uterus changes to discoid shape.
Correct Answer: A
Rationale: A lengthening umbilical cord outside the vagina indicates placental separation and descent, signaling imminent delivery. Decreased bleeding or a non-palpable uterus are not reliable signs, and the uterus becomes globular, not discoid, after placental delivery.
A multigravid client is admitted at 4-cm dilation and requesting pain medication. The nurse gives the client Nubain 15 mg and Phenergan 25 mg slow I.V. push. Within 5 minutes, the client tells the nurse she feels like she needs to have a bowel movement. The nurse should first:
- A. Have naloxone hydrochloride (Narcan) available in the delivery room.
- B. Perform a vaginal examination to determine dilation, effacement, and station.
- C. Prepare for delivery.
- D. Document the client's relief due to pain medication.
Correct Answer: B
Rationale: A sudden urge to have a bowel movement in labor often indicates rapid progression to full dilation or fetal descent. A vaginal examination confirms dilation and station to guide next steps (e.g., preparing for delivery). Naloxone, preparation, or documentation are premature without assessment.
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