Nokea
A newly delivered client is asking to go to the bathroom 45 minutes after delivery. She had an epidural for labor & delivery, has an IV infusing, and every 15 minutes assessments are in progress. To provide the safest care for this client the nurse should:
- A. Ask her to remain in bed until the 15-minute assessments are complete.
- B. Assess client's ability to stand and bear weight before going to the bathroom.
- C. Encourage the client to sit at the side of the bed before ambulating to the bathroom.
- D. Ask the client to ambulate the first time with a staff member at her side.
Correct Answer: B
Rationale: Post-epidural, assessing the client's ability to stand and bear weight ensures safety due to potential residual numbness or weakness. Remaining in bed delays care, sitting first is insufficient, and ambulating with assistance assumes mobility not yet confirmed.
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A client asks about the use of over-the-counter contraceptives. Which of the following would the nurse recommend?
- A. Spermicides and male condoms.
- B. Female condoms and oral contraceptives.
- C. The contraceptive sponge and the patch.
- D. Emergency contraception pills and the diaphragm.
Correct Answer: A
Rationale: Spermicides and male condoms are available over-the-counter and effective when used correctly. Female condoms are also over-the-counter, but oral contraceptives, the patch, and diaphragms require prescriptions. Emergency contraception is over-the-counter but not for regular use.
The nurse is caring for a multiparous client after vaginal delivery of a set of male twins 2 hours ago. The nurse should encourage the mother and husband to:
- A. Bottle-feed the twins to prevent exhaustion and fatigue.
- B. Plan for each parent to spend equal amounts of time with each twin.
- C. Avoid assistance from other family members until attachment occurs.
- D. Relate to each twin individually to enhance the attachment process.
Correct Answer: D
Rationale: Relating to each twin individually fosters unique bonding and attachment.
When teaching a primiparous client who used cocaine during pregnancy how to comfort her fussy neonate, the nurse can advise the mother to:
- A. Tightly swaddle the neonate.
- B. Feed the neonate extra, high-calorie formula.
- C. Keep the neonate in a brightly lit environment.
- D. Touch the baby only when he is crying.
Correct Answer: A
Rationale: Tightly swaddling the neonate provides comfort and reduces overstimulation in cocaine-exposed neonates.
A client is considering the withdrawal method. Which of the following disadvantages should the nurse discuss?
- A. It requires medical supervision.
- B. It has a high failure rate.
- C. It protects against STIs.
- D. It is more effective than condoms.
Correct Answer: B
Rationale: The withdrawal method has a high failure rate due to pre-ejaculate containing sperm and reliance on timing. It does not require medical supervision, does not protect against STIs, and is less effective than condoms.
A newborn weighing 6½ lb is to be given naloxone hydrochloride (Narcan) due to respiratory depression caused by a narcotic administered to the mother shortly before delivery. The dosage is 0.01 mg/kg, administered into the umbilical vein. The vial is labeled 0.4 mg/mL.. How many milligrams would the newborn receive? Round to two decimals.
Correct Answer: 0.03 mg
Rationale: The neonate weighs 6.5 lb (2.95 kg). The dose is 0.01 mg/kg, so 0.01 mg/kg × 2.95 kg = 0.0295 mg, rounded to 0.03 mg.