Nokea
A nurse is caring for a client who inquires about available methods of contraception. Which of the following actions should the nurse take?
- A. Perform unbiased teaching
- B. Assess the client's socioeconomic status
- C. Collect a dietary history
- D. Select the best method of contraception for the client.
Correct Answer: A
Rationale: The nurse should provide comprehensive and unbiased information about the various methods of contraception available. This involves explaining the pros and cons of each method, effectiveness, potential side effects, and how each method aligns with the client's lifestyle and health needs, allowing the client to make an informed decision.
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A nurse is contributing to the plan of care for a newborn who requires phototherapy for hyperbilirubinemia.
Which of the following interventions should the nurse recommend including in the plan?
- A. Reposition the newborn every 2 to 3 hr.
- B. Monitor the newborn's blood glucose level every 2 hr.
- C. Give the newborn 30 ml of distilled water after each feeding.
- D. Apply a water-based ointment to the newborn's skin every 4 to 6 hr.
Correct Answer: A
Rationale: Repositioning the newborn every 2 to 3 hours helps ensure uniform exposure to the phototherapy lights, maximizing the effectiveness of the treatment. This prevents uneven distribution of light and reduces the risk of pressure ulcers or skin breakdown from prolonged immobility.
A nurse is assisting in the care of a client who is 3 hours postpartum and reports complete saturation of their perineal pad in the past 30 minutes.
Which of the following actions is the highest priority?
- A. Perform fundal massage
- B. Weigh the perineal pad
- C. Apply oxygen by face mask
- D. Monitor urine output
Correct Answer: A
Rationale: Complete saturation of the perineal pad within 30 minutes postpartum suggests excessive bleeding, potentially indicating postpartum hemorrhage. Fundal massage stimulates uterine contractions to control bleeding by compressing blood vessels at the placental site, making it the highest priority action.
A nurse is collecting data from a client who has hyperemesis gravidarum.
Which of the following findings should the nurse anticipate?
- A. Increased fundal height
- B. Poor skin turgor
- C. Decreased pulse rate
- D. Proteinuria
Correct Answer: B
Rationale: Poor skin turgor is a common finding in clients with hyperemesis gravidarum due to dehydration. Excessive vomiting leads to fluid loss and dehydration, resulting in poor skin elasticity and turgor.
A nurse is reinforcing teaching with a client about various contraceptive methods. Which of the following statements should the nurse include in the teaching?
- A. You will need to receive a medroxyprogesterone acetate injection once per month.
- B. Combined estrogen-progestin contraceptive pills cause longer periods.
- C. Oral contraceptives decrease the risk for endometrial cancer.
- D. You will need to have your diaphragm replaced every 4 years.
Correct Answer: C
Rationale: Oral contraceptives, particularly combined ones, decrease endometrial cancer risk, an important benefit to include in teaching about contraception.
A nurse is collecting data from a client who is at 26 weeks of gestation and whose last appointment was 1 month ago.
Which of the following findings should the nurse report to the provider?
- A. Pedal edema
- B. BP of 132/84 mm Hg
- C. Weight gain of 1 kg (2.2 lb)
- D. Double vision
Correct Answer: D
Rationale: Double vision can indicate preeclampsia or other serious conditions in pregnancy, requiring prompt reporting for further evaluation and management.