A client who had her first baby three months ago and is breastfeeding her infant tells the nurse that she is currently using the same diaphragm that she used before becoming pregnant. What information should the nurse provide this client?
- A. Use an alternative form of contraception until a new diaphragm is obtained.
- B. After weaning, the diaphragm should be resized.
- C. Avoid intercourse during ovulation until the diaphragm size is reassessed.
- D. If weight gain during pregnancy was no more than 20 pounds, the diaphragm is safe to use.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A 6-year-old with heart failure (HF) gained 2 pounds in the last 24 hours. Which intervention is more important for the nurse to implement?
- A. Graph the daily weight for the past week.
- B. Decrease IV flow rate.
- C. Assess bilateral lung sounds.
- D. Restrict intake of oral fluids.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Just after delivery, a new mother tells the nurse, 'I was unsuccessful breastfeeding my first child, but I would like to try with this baby.' Which intervention is best for the LPN/LVN to implement first?
- A. Assess the husband's feelings about his wife's decision to breastfeed their baby.
- B. Ask the client to describe why she was unsuccessful with breastfeeding her last child.
- C. Encourage the client to develop a positive attitude about breastfeeding to help ensure success.
- D. Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.
Correct Answer: D
Rationale: The correct intervention is to provide immediate assistance to the mother to begin breastfeeding as soon as possible after delivery. This approach helps initiate bonding and successful breastfeeding. Taking action promptly can address the mother's desire to breastfeed and promote positive outcomes for both the mother and the newborn.
A 10-year-old is admitted to the orthopedic unit with a diagnosis of slipped femoral capital epiphysis (SFCE). What focus should the nurse include in this child's plan of care?
- A. Ambulation with a walking cast.
- B. Pin and incision care after surgery.
- C. Use of injections for pain control.
- D. Administration of growth hormone.
Correct Answer: B
Rationale: In the case of slipped femoral capital epiphysis, surgical intervention is often required. Post-surgery care is crucial to prevent complications such as infection and ensure proper healing. This care includes monitoring and managing pin and incision sites for signs of infection, promoting wound healing, and preventing postoperative complications. The focus on pin and incision care is essential for the child's recovery and overall well-being.
A newborn's parents tell the nurse that their baby is already trying to walk. How should the nurse respond?
- A. Encourage the parents to report this to the healthcare provider.
- B. Acknowledge the parents' observation.
- C. Schedule the newborn for further neurological testing.
- D. Explain the newborn's normal stepping reflex.
Correct Answer: D
Rationale: When parents report that their newborn is trying to walk, the nurse should understand that newborns exhibit a stepping reflex, which is a normal developmental response. Explaining this reflex to the parents helps them understand that it is a typical behavior seen in newborns rather than true attempts to walk. Encouraging the parents to report this to the healthcare provider (Choice A) may cause unnecessary concern since the stepping reflex is a normal part of newborn development. Acknowledging the parents' observation (Choice B) is a good communication strategy but providing education on the normal reflex is essential. Scheduling the newborn for further neurological testing (Choice C) is not indicated in this scenario as the stepping reflex is a typical finding in newborns.
A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28 weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions. The LPN/LVN plans to monitor for which primary side effect of terbutaline sulfate?
- A. Drowsiness and bradycardia.
- B. Depressed reflexes and increased respirations.
- C. Tachycardia and a feeling of nervousness.
- D. A flushed, warm feeling and a dry mouth.
Correct Answer: C
Rationale: The primary side effects of terbutaline sulfate are related to its beta-adrenergic effects. Tachycardia and nervousness are common side effects of terbutaline sulfate. Tachycardia is expected due to the drug's beta-agonist properties, while nervousness can result from the stimulation of beta-adrenergic receptors. It is crucial to monitor the client for these side effects to ensure early recognition and appropriate management.
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