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A nurse is counseling a client about the use of spermicides. Which of the following client statements indicates a need for further teaching?
- A. I should use spermicide with a condom for better protection.
- B. Spermicide should be applied 10-30 minutes before intercourse.
- C. Spermicide is effective for up to 24 hours after application.
- D. Spermicide may cause vaginal irritation in some users.
Correct Answer: C
Rationale: Spermicide is effective for about 1 hour after application, not 24 hours, indicating a need for further teaching. The other statements are correct.
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A primigravid client with severe preeclampsia exhibits hyperactive, very brisk patellar reflexes with two beats of ankle clonus present. The nurse documents the patellar reflexes as which of the following?
- A. 1+.
- B. 2+.
- C. 3+.
- D. 4+.
Correct Answer: C
Rationale: Hyperactive reflexes are documented as 3+.
An infant born premature at 34 weeks is receiving gavage feedings. The client holding her infant asks why the nurse places a pacifier in the infant's mouth during these feedings. The nurse replies that the pacifier helps in what ways? Select all that apply.
- A. Teaches the infant to suck and swallow.
- B. Provides oral stimulation.
- C. Keeps oral mucus membranes moist while the tube is in place.
- D. Reminds the infant how to suck.
- E. Stimulates secretions that help gastric emptying.
Correct Answer: B,D
Rationale: The pacifier provides oral stimulation and reminds the infant how to suck, promoting oral motor development.
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.
At a home visit, the nurse assesses a neonate delivered vaginally at 41 weeks' gestation 5 days ago, noting the following findings: frequent hiccups; loose, watery stool in diaper; red rash on face; and dry, peeling skin; which of these findings warrants further assessment?
- A. Frequent hiccups.
- B. Loose, watery stool in diaper.
- C. Pink papular vesicles on the face.
- D. Dry, peeling skin.
Correct Answer: B
Rationale: Loose, watery stool may indicate diarrhea, which requires further assessment to rule out infection or malabsorption.
After instructing a multigravid client diagnosed with mild preeclampsia how to keep a record of fetal movement patterns at home, the nurse determines that the teaching has been effective when the client says that she will count the number of times the baby moves during which of the following time spans?
- A. 30-minute period three times a day.
- B. 45-minute period after lunch each day.
- C. 1-hour period each day.
- D. 12-hour period each week.
Correct Answer: C
Rationale: Counting fetal movements for one hour daily is a common method to monitor fetal well-being.