Nokea
A client is considering the contraceptive injection. Which of the following side effects should the nurse discuss?
- A. Permanent weight loss.
- B. Irregular menstrual bleeding.
- C. Guaranteed regular periods.
- D. Decreased bone density with long-term use.
Correct Answer: B,D
Rationale: The contraceptive injection can cause irregular menstrual bleeding and decreased bone density with long-term use, which are important side effects to discuss. It does not cause permanent weight loss or guarantee regular periods.
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A client asks about the risks of the contraceptive injection. Which of the following would the nurse include?
- A. Increased risk of blood clots.
- B. Decreased bone density with long-term use.
- C. Permanent weight loss.
- D. Guaranteed regular periods.
Correct Answer: B
Rationale: The contraceptive injection may decrease bone density with long-term use, which is a significant risk. It does not significantly increase blood clot risk, cause permanent weight loss, or guarantee regular periods.
While the nurse is caring for a primiparous client on the first postpartum day, the client asks, "How is that woman doing who lost her baby from prematurity?" Which of the following responses by the nurse would be most appropriate?
- A. Ignore the client's question and continue with morning care.
- B. Tell the client "I'm not sure how the other woman is doing today."
- C. Tell the client "I need to ask the woman's permission before discussing her well-being."
- D. Explain to the client that "Nurses are not allowed to discuss other clients on the unit."
Correct Answer: D
Rationale: Nurses must maintain patient confidentiality, making it inappropriate to discuss another client's status.
A primiparous client expresses concern, asking the nurse why her neonate's eyes are crossed. Which of the following would the nurse include when teaching the mother about neonatal strabismus?
- A. The neonate's eyes are unable to focus on light at this time.
- B. The neonate's eye muscles are not fully developed, causing temporary misalignment.
- C. The condition requires immediate surgical correction.
- D. The neonate's vision is permanently impaired.
Correct Answer: B
Rationale: Neonatal strabismus is common due to immature eye muscle coordination and typically resolves as the muscles develop.
Assessment of a 15-year-old primigravid client at term in active labor reveals cervical dilation at 7 cm with complete effacement. The nurse should assess the client for which of the following first?
- A. Uterine inversion.
- B. Cephalopelvic disproportion (CPD).
- C. Rapid third stage of labor.
- D. Decreased ability to push.
Correct Answer: B
Rationale: At 7 cm dilation in active labor, assessing for cephalopelvic disproportion is critical, as it can impede labor progression and may require intervention. Uterine inversion and rapid third stage occur post-delivery, and decreased pushing ability is relevant only in the second stage.
A septic preterm neonate's I.V. was removed due to infiltration. While restarting the I.V., the nurse should carefully assess the neonate for:
- A. Fever.
- B. Hypoglycemia.
- C. Tachycardia.
Correct Answer: C
Rationale: Tachycardia can indicate pain, stress, or cardiovascular compromise during I.V. insertion, especially in a septic preterm neonate.