Nokea
A nurse is counseling a client about the use of a diaphragm. Which of the following instructions should the nurse include?
- A. Insert the diaphragm up to 12 hours before intercourse.
- B. Use spermicide with the diaphragm for each act of intercourse.
- C. Remove the diaphragm immediately after intercourse.
- D. Store the diaphragm in a hot, humid environment.
Correct Answer: B
Rationale: Using spermicide with the diaphragm for each act of intercourse is essential for effectiveness. It can be inserted up to 6 hours before intercourse, should be left in place for at least 6 hours after, and stored in a cool, dry place.
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While assessing a primigravid client admitted at 36 weeks' gestation, the nurse observes multiple bruises on the client's face, neck, and abdomen. When asked about the bruises, the client admits that her boyfriend beats her now and then and says, 'I want to leave him because I'm afraid he will hurt the baby.' Which of the following actions is the nurse's priority?
- A. Tell the client to leave the boyfriend immediately.
- B. Ask the client when she last felt the baby move.
- C. Refer the client to a social worker for possible options.
- D. Report the incident to the unit nursing supervisor.
Correct Answer: C
Rationale: Suspected domestic violence requires referral to a social worker to provide resources (e.g., shelters, counseling) and ensure maternal-fetal safety. Advising immediate leaving is impractical, fetal movement assessment is secondary, and reporting to the supervisor does not directly help the client.
While caring for a multiparous client 4 hours after vaginal delivery of a term neonate, the nurse notes that the mother's temperature is 99.8°F (37.2°C), the pulse is 66 bpm, and the respirations are 18 breaths/minute. Her fundus is firm, midline, and at the level of the umbilicus. The nurse should:
- A. Continue to monitor the client's vital signs.
- B. Assess the client's lochia for large clots.
- C. Notify the client's physician about the findings.
- D. Offer the mother an ice pack for her forehead.
Correct Answer: A
Rationale: A slightly elevated temperature (99.8°F) within the first 24 hours is normal; continued monitoring is appropriate with otherwise normal findings.
While caring for a primigravid client with class II heart disease at 28 weeks' gestation, the nurse would instruct the client to contact her physician immediately if the client experiences which of the following?
- A. Mild ankle edema.
- B. Emotional stress on the job.
- C. Weight gain of 1 lb in 1 week.
- D. Increased dyspnea at rest.
Correct Answer: D
Rationale: Increased dyspnea at rest can indicate worsening heart function.
Following a cesarean delivery for abruptio placentae, a multigravid client tells the nurse, "I feel like such a failure. None of my other deliveries were like this." The nurse's response to the client is based on the understanding of which of the following?
- A. The client will most likely have postpartum blues.
- B. Maternal-infant bonding is likely to be difficult.
- C. The client's feeling of grief is a normal reaction.
- D. This type of delivery was necessary to save the client's life.
Correct Answer: C
Rationale: Grief is a normal reaction to a complicated delivery.
A primiparous client asks how to store breast milk safely at room temperature. The nurse should instruct the client that breast milk can be left at room temperature for up to:
- A. 2 hours.
- B. 4 hours.
- C. 6 hours.
- D. 8 hours.
Correct Answer: C
Rationale: Breast milk is safe at room temperature (up to 77°F) for up to 6 hours, minimizing bacterial growth.