A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client's history should the nurse recognize as a contraindication to oral contraceptives? (Select all that apply.)
- A. Cholecystitis
- B. Hypertension
- C. Human papillomavirus
- D. Migraine headaches
- E. Anxiety Disorder
Correct Answer: A, B, D
Rationale: The correct answers are A, B, and D. Cholecystitis is a contraindication due to the risk of gallbladder disease. Hypertension is a contraindication because estrogen in oral contraceptives can exacerbate hypertension. Migraine headaches are a contraindication due to the increased risk of stroke. Human papillomavirus and anxiety disorder are not contraindications for oral contraceptives.
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A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?
- A. Acrocyanosis.
- B. Transient strabismus.
- C. Jaundice.
- D. Caput succedaneum.
Correct Answer: C
Rationale: The correct answer is C: Jaundice. Jaundice in a newborn within the first 24 hours can indicate pathological conditions like hemolytic disease or liver dysfunction, requiring immediate attention. Acrocyanosis (A) and caput succedaneum (D) are common benign conditions in newborns. Transient strabismus (B) is a temporary eye misalignment that often resolves on its own. Other choices are not provided.
A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in their left calf. Which of the following actions should the nurse take?
- A. Administer aspirin for pain.
- B. Maintain the client on bed rest.
- C. Massage the affected leg every 12 hr.
- D. Apply cold compresses to the affected calf.
Correct Answer: B
Rationale: The correct answer is B: Maintain the client on bed rest. It is essential to maintain the client on bed rest to prevent further complications and to reduce the risk of dislodging the clot. Moving the affected leg could potentially dislodge the clot, leading to serious consequences such as pulmonary embolism. Administering aspirin for pain (choice A) is not appropriate as it can increase the risk of bleeding, especially in a patient receiving heparin. Massaging the affected leg (choice C) can also dislodge the clot and should be avoided. Applying cold compresses (choice D) can potentially exacerbate the situation by causing vasoconstriction and increasing the risk of clot formation.
Which of the following findings should the nurse report to the provider? Select all that apply
- A. Abdominal assessment.
- B. Vaginal Discharge.
- C. Heart rate.
- D. Temperature.
- E. Dyspareunia.
- F. Condom usage.
Correct Answer: B, E
Rationale:
The nurse should report vaginal discharge (B) as it could indicate infection or other issues. Dyspareunia (E) should also be reported as it can indicate underlying problems. Abdominal assessment (A) may be part of routine care but doesn't necessarily require immediate reporting. Heart rate (C) and temperature (D) are vital signs that should be monitored but don't specifically indicate a need for immediate reporting. Condom usage (F) is important for sexual health discussions but does not require reporting to the provider.
A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider?
- A. Blood pressure 105/64 mm Hg.
- B. Heart rate 98/min.
- C. Urine output of 280 mL within 8 hr.
- D. Urine negative for ketones.
Correct Answer: C
Rationale: The correct answer is C: Urine output of 280 mL within 8 hr. In hyperemesis gravidarum, excessive vomiting leads to dehydration and electrolyte imbalance. Monitoring urine output is crucial for assessing renal perfusion. A urine output of 280 mL in 8 hours is low, indicating possible renal impairment. This finding should be reported to the provider for further evaluation and intervention. Choices A, B, and D are within normal limits for a client with hyperemesis gravidarum and receiving IV fluids. Blood pressure of 105/64 mm Hg is acceptable, heart rate of 98/min is slightly elevated but not alarming, and urine negative for ketones indicates adequate fluid replacement.
A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?
- A. Reassess the client in 2 hr.
- B. Administer simethicone.
- C. Assist the client to empty their bladder.
- D. Instruct the client to lie on their right side.
Correct Answer: C
Rationale: The correct answer is C: Assist the client to empty their bladder. After giving birth vaginally, the uterus should be midline and firm. Palpating it above the umbilicus and to the right indicates a full bladder displacing the uterus. Emptying the bladder will allow the uterus to return to its normal position. A: Reassessing in 2 hours is unnecessary as the issue is a full bladder. B: Administering simethicone is for gas relief and not relevant in this situation. D: Instructing the client to lie on their right side does not address the underlying issue of the full bladder.