Nokea
A nurse is counseling a client about the use of emergency contraception. Which of the following client statements indicates understanding?
- A. I should take it within 72 hours of unprotected intercourse.
- B. It can be used as a regular contraceptive method.
- C. It requires a surgical procedure.
- D. It is 100% effective in preventing pregnancy.
Correct Answer: A
Rationale: Emergency contraception is most effective when taken within 72 hours of unprotected intercourse. It is not for regular use, does not require surgery, and is not 100% effective.
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Which of the following observations is expected when the nurse is assessing the gestational age of a neonate delivered at term?
- A. Ear lying flat against the head.
- B. Absence of rugae in the scrotum.
- C. Sole creases covering the entire foot.
- D. Square window sign angle of 90 degrees.
Correct Answer: C
Rationale: Sole creases covering the entire foot are characteristic of a term neonate, indicating full gestational maturity.
The nurse prepares a client for lumbar epidural anesthesia. Before anesthesia administration, the nurse instructs the client to assume which of the following positions?
- A. Sitting with back arched.
- B. Lying flat on back.
- C. Side-lying with knees bent.
- D. Prone with head elevated.
Correct Answer: A
Rationale: The sitting position with the back arched (e.g., 'shrimp' position) provides optimal access to the lumbar spine for epidural placement. Other positions do not facilitate needle insertion as effectively.
A nurse is counseling a client about the use of a diaphragm. Which of the following client statements indicates a need for further teaching?
- A. I need to use spermicide with the diaphragm.
- B. I can insert the diaphragm up to 6 hours before intercourse.
- C. I should leave the diaphragm in place for at least 6 hours after intercourse.
- D. I can reuse the diaphragm without cleaning it.
Correct Answer: D
Rationale: The diaphragm must be cleaned after each use to maintain hygiene and effectiveness. The other statements are correct, indicating a need for further teaching about cleaning.
The nurse and a nursing assistant are caring for clients in a birthing center. Which of the following tasks should the nurse delegate to the nursing assistant? Select all that apply.
- A. Removing a Foley catheter from a preeclamptic client.
- B. Assisting an active labor client with breathing and relaxation.
- C. Ambulating a postcesarean client to the bathroom.
- D. Calculating hourly I.V. totals for a preterm labor client.
- E. Intake and output catheterization for culture and sensitivity.
- F. Calling a report of normal findings to the health care provider.
- G. Removing lunch trays and documenting lunch intake.
Correct Answer: C,G
Rationale: Delegating ambulation and lunch tray removal is appropriate for a nursing assistant.
When developing the plan of care for a multigravid client with class III heart disease, which of the following areas should the nurse expect to assess frequently?
- A. Dehydration.
- B. Nausea and vomiting.
- C. Iron-deficiency anemia.
- D. Tachycardia.
Correct Answer: D
Rationale: Class III heart disease indicates significant cardiac limitation, making tachycardia a critical sign of cardiac stress during labor. Frequent assessment ensures early detection of decompensation. Dehydration, nausea, or anemia are less immediate concerns.