Nokea
A client who is considering a contraceptive implant asks the nurse about its advantages. Which of the following would the nurse include in the response?
- A. It provides protection against sexually transmitted infections.
- B. It is effective for up to 3 years and is reversible.
- C. It requires daily administration for effectiveness.
- D. It is suitable for women with a history of blood clots.
Correct Answer: B
Rationale: The contraceptive implant is effective for up to 3 years and is reversible, making it a long-acting, convenient option. It does not protect against STIs, is not taken daily, and is generally safe for women with clotting risks as it is progestin-only.
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When developing a teaching plan for a primigravid client with insulin-dependent diabetes about monitoring blood glucose control and insulin dosages at home, which of the following would the nurse expect to include as a desired target range for blood glucose levels?
- A. 40 to 60 mg/dL between 2:00 and 4:00 p.m.
- B. 60 to 100 mg/dL before meals and bedtime snacks.
- C. 110 to 140 mg/dL before meals and bedtime snacks.
- D. 140 to 160 mg/dL 1 hour after meals.
Correct Answer: B
Rationale: Target range before meals and bedtime snacks is 60-100 mg/dL.
A male neonate born at 38 weeks' gestation by cesarean delivery after prolonged rupture of the membranes and a maternal oral temperature of 102°F (38.8°C) is being observed for signs and symptoms of infection. Which of the following would alert the nurse to notify the physician?
- A. Leukocytosis.
- B. Apical heart rate of 132 bpm.
- C. Alertness changes.
- D. Warm, moist skin.
Correct Answer: A
Rationale: Leukocytosis is a sign of infection and warrants notifying the physician, especially given the maternal fever and prolonged rupture of membranes.
The nurse is assessing a multiparous client 12 hours after vaginal delivery. Which finding requires immediate intervention?
- A. Fundus firm, 1 cm above umbilicus.
- B. Lochia rubra with small clots.
- C. Perineal pain rated 3/10.
- D. Pulse 100 bpm, temperature 100.4°F (38°C).
Correct Answer: D
Rationale: An elevated pulse and temperature may indicate infection or hemorrhage, requiring prompt intervention.
A newborn is diagnosed with fetal alcohol syndrome. The nurse is teaching this mother what to expect when she goes home with her baby. The nurse determines the mother needs further instruction when she says which of the following?
- A. The way my baby's face looks now will stay that way.'
- B. My baby may be irritable as a newborn.'
- C. I may need some help coping with my newborn.'
- D. My baby will be fine soon after we are home.'
Correct Answer: D
Rationale: FAS is a lifelong condition, and the neonate will not be 'fine' soon after going home, indicating a need for further instruction.
Which of the following would the nurse include in the teaching plan for a primiparous client about the frequency of breast-feeding the neonate during the first few days?
- A. Feeding the neonate whenever he or she cries.
- B. Restricting feedings to 1 to 2 minutes per side.
- C. Feeding the neonate for at least 10 minutes per side.
- D. Maintaining feeding for 20 to 30 minutes per side.
Correct Answer: C
Rationale: Feeding for at least 10 minutes per side ensures adequate milk transfer and stimulation of milk production.