Nokea
A client has just had a cesarean section for a prolapsed cord. In reviewing the client's history, which of the following factors places a client at risk for cord prolapse? Select all that apply.
- A. -2 station.
- B. Low birth weight infant.
- C. Rupture of membranes.
- D. Breech presentation.
- E. Prior abortion.
- F. Low lying placenta.
Correct Answer: A,B,C,D,F
Rationale: These factors increase the risk of cord prolapse.
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A nurse is discussing the contraceptive ring with a client. Which of the following client statements indicates understanding?
- A. I can remove the ring for up to 3 hours if needed.
- B. The ring is replaced every week.
- C. The ring requires daily insertion.
- D. The ring provides long-term contraception for 5 years.
Correct Answer: A
Rationale: The vaginal contraceptive ring can be removed for up to 3 hours if needed without losing effectiveness. It is replaced every 3 weeks (not weekly), not inserted daily, and provides contraception for one cycle, not 5 years.
A female neonate delivered vaginally at term with a cleft lip and cleft palate is admitted to the regular nursery. Which of the following actions should the nurse do the first time that the parents visit the neonate in the nursery?
- A. Explain the surgical interventions that will be performed.
- B. Stress that this defect is not life-threatening.
- C. Emphasize the neonate's normal characteristics.
- D. Reassure the parents about the success rate of the surgery.
Correct Answer: C
Rationale: Emphasizing the neonate's normal characteristics helps promote bonding and reduces parental anxiety during the initial visit.
A preterm neonate is unable to breast- or bottle-feed. The physician writes an order to feed the neonate via nasogastric (NG) tube. When choosing an NG feeding tube for a neonate, the nurse should base the tube size on the neonate's:
- A. Disease process.
- B. Gestational age.
- C. Length.
- D. Weight.
Correct Answer: B
Rationale: Gestational age determines the appropriate NG tube size, as it correlates with the neonate's anatomical development.
A client is considering permanent contraception. Which of the following client statements indicates a need for further teaching?
- A. Tubal ligation is considered permanent.
- B. Vasectomy requires a follow-up sperm count.
- C. Tubal ligation will cause early menopause.
- D. Both procedures require general anesthesia.
Correct Answer: C
Rationale: Tubal ligation does not cause early menopause, as it only blocks the fallopian tubes and does not affect ovarian hormone production. The other statements are correct, though anesthesia type may vary.
The nurse discovers a medication error where a postpartum client received 400 mg of ibuprofen instead of 800 mg. The nurse should:
- A. Monitor the client for adverse effects.
- B. Administer the remaining 400 mg immediately.
- C. Notify the physician and complete an incident report.
- D. Document the dose as administered without reporting.
Correct Answer: C
Rationale: Notifying the physician and filing an incident report ensures patient safety and proper follow-up.