Nokea
A nurse is counseling a client about the fertility awareness method. Which of the following client statements indicates a need for further teaching?
- A. I will track my basal body temperature daily.
- B. I will monitor my cervical mucus for changes.
- C. I will avoid intercourse during my fertile days.
- D. I can rely on this method even with irregular cycles.
Correct Answer: D
Rationale: The fertility awareness method is less reliable with irregular cycles, as ovulation is harder to predict. The other statements reflect correct understanding, indicating a need for further teaching about cycle regularity.
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While caring for a primipara diagnosed with deep vein thrombosis at 48 hours postpartum who is receiving treatment with bed rest and intravenous heparin therapy, the nurse should contact the client's physician immediately if the client exhibited which of the following?
- A. Pain in her calf.
- B. Dyspnea.
- C. Hypertension.
- D. Bradycardia.
Correct Answer: B
Rationale: Dyspnea may indicate a pulmonary embolism, a life-threatening complication requiring immediate attention.
A primigravida admitted to the hospital with a diagnosis of hyperemesis gravidarum is placed on nothing-by-mouth(NPO) status and is receiving intravenous(IV) fluid replacement therapy. In planning this client's care, the nurse should collaborate with the health care provider(HCP) to carry out which of the following?
- A. Withhold oral fluids indefinitely until acidosis is corrected.
- B. Give oral fluids in small quantities whenever the client desires.
- C. Per HCP orders, provide clear liquids by mouth after 24 hours if vomiting subsides.
- D. Withhold oral fluids until total parenteral nutrition replaces lost electrolytes.
Correct Answer: C
Rationale: Gradual reintroduction of oral fluids is appropriate once vomiting subsides.
When performing Leopold's maneuvers on a primigravid client, the nurse is palpating the uterus as shown below. Which of the following maneuvers is the nurse performing?
- A. First maneuver.
- B. Second maneuver.
- C. Third maneuver.
- D. Fourth maneuver.
Correct Answer: C
Rationale: The third Leopold's maneuver involves palpating the suprapubic area to determine the presenting part and its engagement, typically performed as described in the context. The first identifies the fundal contents, the second locates the fetal back, and the fourth assesses cephalic prominence.
The nurse notices that a client who has just delivered her infant is short of breath, ashen in color, and begins to cough. She becomes limp on the delivery table. Determine the nursing actions in the order they should occur.
- A. Open airway using head tilt-chin lift.
- B. Ask staff to activate emergency response system.
- C. Establish unresponsiveness.
- D. Give 2 breaths.
- E. Check the pulse.
Correct Answer: C,A,D,E,B
Rationale: Assess responsiveness first, then secure the airway, breathing, and circulation.
Which of the following indicates successful latch-on during a breast-feeding session?
- A. Neonate's lips are flanged outward.
- B. Mother reports sharp pain throughout feeding.
- C. Neonate's cheeks are dimpled.
- D. Mother hears clicking sounds during sucking.
Correct Answer: A
Rationale: Flanged lips indicate a proper latch, ensuring effective milk transfer and preventing nipple trauma.