Nokea
A nurse is counseling a client about the use of a contraceptive sponge. Which of the following client statements indicates understanding?
- A. The sponge can be inserted just before intercourse.
- B. I will reuse the sponge after rinsing it.
- C. The sponge protects against STIs.
- D. I need to apply additional spermicide after insertion.
Correct Answer: A
Rationale: The contraceptive sponge can be inserted just before intercourse, providing immediate protection. It cannot be reused, does not protect against STIs, and contains spermicide, so additional application is not needed.
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A nurse is teaching a client about the use of male condoms. Which of the following instructions should the nurse include?
- A. Use a water-based lubricant with latex condoms.
- B. Store condoms in a hot environment to maintain flexibility.
- C. Apply the condom after ejaculation for best results.
- D. Reuse condoms if they are undamaged.
Correct Answer: A
Rationale: Using a water-based lubricant with latex condoms prevents breakage and enhances comfort. Condoms should be stored in a cool, dry place, applied before any genital contact, and never reused.
While performing a complete assessment of a term neonate, which of the following findings would alert the nurse to notify the pediatrician?
- A. Red reflex in the eyes.
- B. Expiratory grunt.
- C. Respiratory rate of 45 breaths/minute.
- D. Prominent xiphoid process.
Correct Answer: B
Rationale: An expiratory grunt is a sign of respiratory distress and warrants immediate notification of the pediatrician.
At 32 weeks' gestation, a 15-year-old primigravid client who is 5 feet, 2 inches tall has gained a total of 20 lb, with a 1-lb gain in the last 2 weeks. Urinalysis reveals negative glucose and a trace of protein. The nurse should advise the client that which of the following factors increases her risk for preeclampsia?
- A. Total weight gain.
- B. Short stature.
- C. Adolescent age group.
- D. Proteinuria.
Correct Answer: C
Rationale: Adolescents are at higher risk for preeclampsia due to incomplete physical maturity.
A client who is considering a contraceptive implant asks the nurse about its advantages. Which of the following would the nurse include in the response?
- A. It provides protection against sexually transmitted infections.
- B. It is effective for up to 3 years and is reversible.
- C. It requires daily administration for effectiveness.
- D. It is suitable for women with a history of blood clots.
Correct Answer: B
Rationale: The contraceptive implant is effective for up to 3 years and is reversible, making it a long-acting, convenient option. It does not protect against STIs, is not taken daily, and is generally safe for women with clotting risks as it is progestin-only.
A newborn is diagnosed with fetal alcohol syndrome. The nurse is teaching this mother what to expect when she goes home with her baby. The nurse determines the mother needs further instruction when she says which of the following?
- A. The way my baby's face looks now will stay that way.'
- B. My baby may be irritable as a newborn.'
- C. I may need some help coping with my newborn.'
- D. My baby will be fine soon after we are home.'
Correct Answer: D
Rationale: FAS is a lifelong condition, and the neonate will not be 'fine' soon after going home, indicating a need for further instruction.