Nokea
A nurse is counseling a client about the contraceptive sponge. Which of the following instructions should the nurse include?
- A. Insert the sponge at least 1 hour before intercourse.
- B. Leave the sponge in place for at least 6 hours after intercourse.
- C. Reuse the sponge if it is undamaged.
- D. Apply spermicide to the sponge after insertion.
Correct Answer: B
Rationale: The contraceptive sponge should be left in place for at least 6 hours after intercourse to ensure effectiveness. It should be inserted just before intercourse, cannot be reused, and contains spermicide, so additional application is not needed.
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A 24-year-old primipara who has delivered a healthy neonate in the hospital's birthing center plans to bottle-feed her neonate. When developing the nutritional teaching plan for the mother, the nurse should determine that the number of calories required by the neonate each day per pound of body weight is which of the following?
- A. 30 to 35.
- B. 40 to 45.
- C. 50 to 55.
- D. 60 to 65.
Correct Answer: C
Rationale: Neonates require approximately 50-55 calories per pound of body weight daily for growth and development.
The physician orders an intramuscular injection of phytonadione (AquaMEPHYTON) for a term neonate. The nurse explains to the mother that this medication is used to prevent which of the following?
- A. Hypoglycemia.
- B. Hyperbilirubinemia.
- C. Hemorrhage.
- D. Polycythemia.
Correct Answer: C
Rationale: Phytonadione (vitamin K) is administered to newborns to prevent hemorrhagic disease due to low vitamin K levels, which are necessary for blood clotting.
Which of the following statements about a fetal biophysical profile would be incorporated into the teaching plan for a primigravid client with insulin-dependent diabetes?
- A. It determines fetal lung maturity.
- B. It is noninvasive using real-time ultrasound.
- C. It will correlate with the newborn's Apgar score.
- D. It requires the client to have an empty bladder.
Correct Answer: B
Rationale: Biophysical profiles are noninvasive and use real-time ultrasound.
A neonate born by cesarean delivery at 42 weeks' gestation, weighing 4.1 kg (9 lb, 1 oz), with Apgar scores of 8 at 1 minute and 9 at 5 minutes after birth, develops an increased respiratory rate and tremors of the hands and feet 2 hours postpartum. Which of the following nursing diagnoses would be the priority?
- A. Ineffective airway clearance related to postterm gestational age.
- B. Hyperthermia related to large size and use of a radiant warmer.
- C. Decreased cardiac output related to difficult delivery.
- D. Imbalanced nutrition: Less than body requirements related to depleted glycogen stores.
Correct Answer: D
Rationale: Tremors and increased respiratory rate suggest hypoglycemia due to depleted glycogen stores, a common issue in post-term neonates.
Following an epidural and placement of internal monitors, a client's labor is augmented. Contractions are lasting greater than 90 seconds and occurring every 1½ minutes. The uterine resting tone is greater than 20 mm mercury with a nonreassuring fetal heart rate and pattern. Which of the following actions should the nurse take first?
- A. Notify the health care provider.
- B. Turn off the oxytocin (Pitocin) infusion.
- C. Turn the client to her left side.
- D. Increase the maintenance I.V. fluids.
Correct Answer: B
Rationale: Hyperstimulation (contractions >90 seconds, frequent, with high resting tone) and nonreassuring fetal heart rate indicate fetal distress. Stopping oxytocin is the first step to reduce uterine activity and improve fetal oxygenation. Repositioning, notifying the provider, or increasing fluids follow.