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A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication?
- A. Depression
- B. Polyuria
- C. Hypotension
- D. Urticaria
Correct Answer: A
Rationale: The correct answer is A: Depression. Combined oral contraceptives can cause mood changes, including depression, as an adverse effect due to hormonal fluctuations. This is important for the nurse to include in teaching to monitor the client's mental health. Polyuria (B) is excessive urination, not associated with oral contraceptives. Hypotension (C) is low blood pressure, not a common adverse effect of oral contraceptives. Urticaria (D) is hives, typically not linked to this medication.
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A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception. Which of the following instructions should the nurse include?
- A. You should have your provider refit you for a new diaphragm.'
- B. You should use an oil-based vaginal lubricant when inserting your diaphragm.'
- C. You should keep the diaphragm in place for at least 4 hours after intercourse.'
- D. You should store your diaphragm in sterile water after each use.'
Correct Answer: A
Rationale: The correct answer is A: "You should have your provider refit you for a new diaphragm." This is important because postpartum changes in the body can affect the fit of the diaphragm. A refitting ensures proper size and fit for effective contraception. Choice B is incorrect because oil-based lubricants can damage latex diaphragms. Choice C is incorrect as the diaphragm should be kept in place for at least 6-8 hours, not 4 hours, for effective contraception. Choice D is incorrect as diaphragms should be stored dry, not in sterile water, to prevent damage.
A nurse is assessing a newborn who was born postterm. Which of the following findings should the nurse expect?
- A. Large deposits of subcutaneous fat
- B. Thin covering of fine hair on shoulders and back
- C. Nails extending over tips of fingers
- D. Pale, translucent skin
Correct Answer: C
Rationale: The correct answer is C: Nails extending over tips of fingers. Postterm newborns have longer nails due to the extended intrauterine period. Large deposits of subcutaneous fat (A) are common in term and postterm newborns, not specific to postterm. Thin covering of fine hair on shoulders and back (B) is typical in preterm newborns, not postterm. Pale, translucent skin (D) is seen in preterm infants, not postterm. Therefore, the most appropriate finding to expect in a postterm newborn is nails extending over tips of fingers.
A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?
- A. Substernal retractions
- B. Acrocyanosis
- C. Overlapping suture lines
- D. Head circumference 33 cm (13 in)
Correct Answer: A
Rationale: The correct answer is A: Substernal retractions. Substernal retractions in a newborn indicate respiratory distress and can be a sign of a serious issue such as respiratory distress syndrome. This finding requires immediate attention from the provider to assess and manage the newborn's respiratory status. Acrocyanosis (B) is a common finding in newborns and is not typically concerning. Overlapping suture lines (C) can be normal in newborns due to molding during birth. A head circumference of 33 cm (13 in) (D) falls within the normal range for a newborn and does not require immediate reporting.
A nurse is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?
- A. Check the client's temperature.
- B. Observe for uterine contractions.
- C. Administer Rho(D) immune globulin.
- D. Monitor the FHR.
Correct Answer: C
Rationale: The correct answer is C: Administer Rho(D) immune globulin. This is the priority intervention following an amniocentesis in an Rh-negative client at 15 weeks gestation to prevent Rh isoimmunization. Administering Rho(D) immune globulin helps prevent the mother's immune system from forming antibodies against Rh-positive fetal blood cells, which could lead to hemolytic disease in the newborn. Checking the client's temperature (A) is not the priority as there is no immediate risk related to the procedure. Observing for uterine contractions (B) is important but not the priority immediately post-procedure. Monitoring the FHR (D) is important but not the priority at this time.
A nurse is caring for a client who is receiving oxytocin via continuous IV infusion and is experiencing persistent late decelerations in the FHR. After discontinuing the infusion, which of the following actions should the nurse take?
- A. Instruct the client to bear down and push with contractions.
- B. Administer oxygen at 10 L/min via nonrebreather facemask.
- C. Place the client in a supine position.
- D. Initiate an amnioinfusion.
Correct Answer: B
Rationale: The correct answer is B: Administer oxygen at 10 L/min via nonrebreather facemask. Late decelerations in the fetal heart rate (FHR) indicate uteroplacental insufficiency, which could lead to fetal hypoxia. Providing oxygen at 10 L/min via a nonrebreather facemask helps improve oxygenation for both the mother and the fetus. This intervention aims to increase oxygen delivery to the placenta and subsequently improve fetal oxygenation. In contrast, option A (instructing the client to bear down and push with contractions) can further compromise fetal oxygenation. Option C (placing the client in a supine position) can worsen uteroplacental perfusion. Option D (initiating an amnioinfusion) is not indicated for late decelerations and does not address the underlying cause of fetal hypoxia.