Nokea
A client is considering the hormonal IUD. Which of the following client statements indicates a need for further teaching?
- A. The IUD may reduce my menstrual bleeding.
- B. The IUD can stay in place for several years.
- C. The IUD will prevent ovulation every month.
- D. The IUD does not protect against STIs.
Correct Answer: C
Rationale: The hormonal IUD does not primarily prevent ovulation every month; it mainly thins the uterine lining and thickens cervical mucus. The other statements are correct, indicating a need for further teaching.
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A primigravid client at 37 weeks' gestation has been hospitalized for several days with severe pregnancy-induced hypertension. While caring for the client, the nurse observes that the client is beginning to have a seizure. Which of the following actions should the nurse do first?
- A. Pad the side rails of the client's bed.
- B. Turn the client to the right side.
- C. Insert a padded tongue blade into the client's mouth.
- D. Call for immediate assistance in the client's room.
Correct Answer: D
Rationale: A seizure in pregnancy-induced hypertension (eclampsia) is a medical emergency. Calling for immediate assistance ensures rapid intervention (e.g., magnesium sulfate). Padding rails, repositioning, or inserting a tongue blade (which is outdated) are secondary.
When developing the initial plan of care for a neonate who was born at 41 weeks' gestation, was diagnosed with meconium aspiration syndrome (MAS), and requires mechanical ventilation, which of the following should the nurse include:
- A. Care of an umbilical arterial line.
- B. Frequent ultrasound scans.
- C. Orogastric feedings as soon as possible.
- D. Assessment for symptoms of hyperglycemia.
Correct Answer: A
Rationale: Care of an umbilical arterial line is necessary for monitoring blood gases and blood pressure in a neonate on mechanical ventilation.
Which of the following would lead the nurse to suspect retinopathy of prematurity (ROP) when assessing a neonate at 32 weeks' gestation who weighs 2,000 g ?
- A. Sunken orbital sockets.
- B. Strabismus.
- C. Reaction to bright light.
- D. Constricted retinal vessels.
Correct Answer: D
Rationale: Constricted retinal vessels are a sign of ROP, indicating abnormal retinal vascular development.
A primiparous client who is bottle-feeding her neonate at 12 hours after birth asks the nurse, "When will my menstrual cycle return?" Which of the following responses by the nurse would be most appropriate?
- A. Your menstrual cycle will return in 3 to 4 weeks.
- B. It will probably be 6 to 10 weeks before it starts again.
- C. You can expect your menses to start in 12 to 14 weeks.
- D. Your menses will return in 16 to 18 weeks.
Correct Answer: B
Rationale: For bottle-feeding mothers, menstruation typically resumes 6 to 10 weeks postpartum due to the absence of breastfeeding's hormonal suppression.
A primigravid client with class II heart disease who is visiting the clinic at 8 weeks' gestation tells the nurse that she has been maintaining a low-sodium, 1,800-calorie diet. Which of the following instructions should the nurse give the client?
- A. Avoid folic acid supplements to prevent megaloblastic anemia.
- B. Severely restrict sodium intake throughout the pregnancy.
- C. Take iron supplements with milk to enhance absorption.
- D. Increase caloric intake to 2,200 calories daily to promote fetal growth.
Correct Answer: D
Rationale: Increased caloric intake supports fetal growth without compromising maternal health.