Nokea
A nurse and an LPN are working in the labor and delivery unit. Of the following assessments and interventions that must be done immediately, which should the nurse assign to the LPN?
- A. Complete an initial assessment on a client.
- B. Increase the oxytocin (Pitocin) rate on a laboring client.
- C. Perform a straight catheterization for protein analysis.
- D. Assess a laboring client for a change in labor pattern.
Correct Answer: C
Rationale: An LPN can perform a straight catheterization for protein analysis, a technical task within their scope. Initial assessments, oxytocin adjustments, and labor pattern assessments require RN judgment and expertise.
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A client asks about the effectiveness of emergency contraception. Which of the following responses by the nurse is accurate?
- A. Emergency contraception is 100% effective if taken within 24 hours.
- B. Emergency contraception is most effective when taken within 72 hours of unprotected intercourse.
- C. Emergency contraception can be used as a regular contraceptive method.
- D. Emergency contraception requires a surgical procedure.
Correct Answer: B
Rationale: Emergency contraception is most effective when taken within 72 hours of unprotected intercourse, with efficacy decreasing over time. It is not 100% effective, not suitable for regular use, and does not require surgery.
Four days after a vaginal delivery, the client visits the clinic complaining of excessive lochia rubra with clots. The physician orders methylergonovine maleate (Methergine), 0.2 mg intramuscularly. Before administering this drug, the nurse should assess:
- A. Blood pressure.
- B. Pulse rate.
- C. Breath sounds.
- D. Bowel sounds.
Correct Answer: A
Rationale: Methylergonovine can cause hypertension, so blood pressure assessment is essential before administration.
On the first postpartum day, the primiparous client reports perineal pain of 5 on a scale of 1 to 10 that was unrelieved by ibuprofen 800 mg given 2 hours ago. The nurse should further assess the client for:
- A. Puerperal infection.
- B. Vaginal lacerations.
- C. History of drug abuse.
- D. Perineal hematoma.
Correct Answer: D
Rationale: Persistent perineal pain unrelieved by ibuprofen suggests a perineal hematoma, which requires further assessment.
A primiparous client is on a regular diet 24 hours postpartum. She is from Guatemala and speaks little English. The client's mother asks the nurse if she can bring her daughter some "special foods from home." The nurse responds, based on the understanding about which of the following?
- A. Foods from home are generally discouraged on the postpartum unit.
- B. The mother can bring the daughter any foods that she desires.
- C. This is permissible as long as the foods are nutritious and high in iron.
- D. The client's physician needs to give permission for the foods.
Correct Answer: C
Rationale: Nutritious, iron-rich foods support postpartum recovery and respect cultural preferences.
A primiparous client who is bottle-feeding her neonate asks, "When should I start giving the baby solid foods?" The nurse instructs the client to introduce solid foods no sooner than at which age?
- A. 2 months.
- B. 6 months.
- C. 8 months.
- D. 10 months.
Correct Answer: B
Rationale: Solid foods are introduced around 6 months when the infant's digestive system is more mature.