Nokea
A client is considering the contraceptive injection. Which of the following client statements indicates understanding?
- A. The injection is given every 3 months.
- B. The injection protects against STIs.
- C. The injection requires daily administration.
- D. The injection causes permanent infertility.
Correct Answer: A
Rationale: The contraceptive injection is given every 3 months, providing sustained contraception. It does not protect against STIs, is not taken daily, and does not cause permanent infertility.
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A neonate is admitted to the neonatal intensive care unit for observation with a diagnosis of probable meconium aspiration syndrome (MAS). The neonate weighs10 lb, 4 oz (4,650 g) and is at 41 weeks' gestation. Which of the following nursing diagnoses would be the priority for this neonate?
- A. Impaired skin integrity related to post-term status.
- B. Imbalanced nutrition: More than body requirements related to large size.
- C. Risk for impaired parent-infant-child attachment related to transfer to the intensive care unit.
- D. Impaired gas exchange related to the effects of respiratory distress.
Correct Answer: D
Rationale: Impaired gas exchange is the priority due to the respiratory distress associated with meconium aspiration syndrome.
A primigravid client in active labor has had no anesthesia. The client's cervix is 7 cm dilated, and she is starting to feel considerable discomfort during the first 10 cm to the client's sacral client is a left side-lying position. The nurse should encourage which of the following?
- A. Rapid, shallow chest breathing.
- B. Deep chest breathing.
- C. Rapid pant-blow breathing.
- D. Slow abdominal breathing.
Correct Answer: D
Rationale: Slow abdominal breathing promotes relaxation and oxygenation, helping manage discomfort in active labor without anesthesia. Rapid or shallow breathing may lead to hyperventilation, and deep chest breathing is less effective for pain control.
During a home visit to a breast-feeding primiparous client at 1 week postpartum, the client tells the nurse that her nipples have become sore and cracked from the feedings. Which of the following should the nurse instruct the client to do?
- A. Wipe off any lanolin creams from the nipple before each feeding.
- B. Position the baby with the entire areola in the baby's mouth.
- C. Feed the baby less often for the next several days.
- D. Use a mild soap while in the shower to prevent an infection.
Correct Answer: B
Rationale: Proper positioning with the areola in the baby's mouth prevents and heals sore nipples.
A full-term client is admitted for an induction of labor. The health care provider has assigned a Bishop score of 10. Which drug would the nurse anticipate administering to this client?
- A. Oxytocin (Pitocin) 10 units in 500 mL D5W.
- B. Prostaglandin gel (Prepidil) 0.5 mg.
- C. Misoprostol (Cytotec) 50 mcg P.O.
- D. Dinoprostone (Cervidil) 10 mg.
Correct Answer: A
Rationale: A Bishop score of 10 indicates a favorable cervix for induction, so oxytocin (Pitocin) is appropriate to initiate contractions. Prostaglandins (Prepidil, Cervidil, Cytotec) are used for cervical ripening when the cervix is unfavorable.
A multiparous client delivers dizygotic twins at 37 weeks' gestation. The twin neonates require additional hospitalization after the client is discharged. In planning the family's care, an appropriate goal for the nurse to formulate is that, while the twins are hospitalized, the parents will do which of the following?
- A. Discuss how they will cope with twin infants at home.
- B. Participate in care of the twins as much as possible.
- C. Take turns providing 24-hour observation of the twins.
- D. Identify complications that may occur as the twins develop.
Correct Answer: B
Rationale: Parental participation in twin care during hospitalization promotes bonding, confidence, and skill development. Discussing coping, 24-hour observation, or identifying complications are less immediate or unrealistic.