Nokea
A multigravid client admitted to the labor area is scheduled for a cesarean delivery under spinal anesthesia. After instructions by the anesthesiologist, the nurse determines that the client has understood the instructions when she says which of the following?
- A. The medication will be administered while I am in a side-lying position.'
- B. The anesthetic may cause a severe headache which is treatable.'
- C. My blood pressure may increase if I lie down too soon after the injection.'
- D. I can expect immediate anesthesia that can be reversed very easily.'
Correct Answer: B
Rationale: Spinal anesthesia carries a risk of post-dural puncture headache, which is treatable (e.g., with a blood patch). The side-lying position is for epidural, not spinal, anesthesia; blood pressure typically decreases; and spinal anesthesia is not easily reversed.
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A nurse is counseling a client about the use of a vaginal contraceptive ring. Which of the following client statements indicates understanding?
- A. I should remove the ring every night before bed.
- B. The ring is left in place for three weeks, then removed for one week.
- C. I need to replace the ring every two weeks.
- D. The ring protects against HIV transmission.
Correct Answer: B
Rationale: The vaginal contraceptive ring is left in place for three weeks, then removed for one week to allow a withdrawal bleed. It is not removed nightly, replaced every two weeks, or protective against HIV.
A neonate is delivered by primary cesarean section at 36 weeks' gestation. The temperature in the delivery room is 70F. To prevent heat loss from convection, which action should the nurse take?
- A. Dry the neonate quickly after delivery.
- B. Keep the neonate away from air conditioning vests.
- C. Place the neonate away from outside windows.
- D. Phewarm the bed.
Correct Answer: B
Rationale: The neonate should be kept away from drafts, such as from air conditioning vents, which may cause heat loss by convection. Convection involves heat loss due to air movement, and avoiding drafts is the most effective action.
A client is considering the withdrawal method. Which of the following client statements indicates understanding?
- A. It requires careful timing and control.
- B. It is more effective than oral contraceptives.
- C. It provides protection against STIs.
- D. It is 100% effective with perfect use.
Correct Answer: A
Rationale: The withdrawal method requires careful timing and control to be effective. It is less effective than oral contraceptives, does not protect against STIs, and is not 100% effective, even with perfect use.
Assessment of a 16-year-old nulligravid client who visits the clinic and asks for information on contraceptives reveals a menstrual cycle of 28 days. The nurse formulates a nursing diagnosis of Deficient knowledge related to ovulation and fertility management. Which of the following would be important to include in the teaching plan for the client?
- A. The ovum survives for 96 hours after ovulation, making conception possible during this time.
- B. The basal body temperature falls at least 0.2°F after ovulation has occurred.
- C. Ovulation usually occurs on day 14, plus or minus 2 days, before the onset of the next menstrual cycle.
- D. Most women can tell they have ovulated because of severe pain and thick, scant cervical mucus.
Correct Answer: C
Rationale: Ovulation typically occurs around day 14 (plus or minus 2 days) before the next menstrual cycle in a 28-day cycle, which is critical for understanding fertility windows. The ovum survives for about 12-24 hours, not 96 hours, and basal body temperature rises after ovulation.
The nurse is performing effleurage for a primigravid client in early labor. The nurse should do which of the following?
- A. Deep kneading of superficial muscles.
- B. Secure grasping of muscular tissues.
- C. Light stroking of the skin surface.
- D. Prolonged pressure on specific sites.
Correct Answer: C
Rationale: Effleurage is a light, stroking massage of the skin surface (often the abdomen) to promote relaxation and pain relief during labor. Deep kneading, grasping, or prolonged pressure describe other massage techniques not specific to effleurage.