Nokea
A nurse is discussing sterilization with a male client. Which of the following client statements indicates understanding?
- A. A vasectomy requires a follow-up sperm count.
- B. A vasectomy prevents testosterone production.
- C. A vasectomy is effective immediately.
- D. A vasectomy is easily reversible.
Correct Answer: A
Rationale: A vasectomy requires a follow-up sperm count to confirm sterility. It does not affect testosterone production, is not effective immediately, and reversal is not always successful.
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The nurse makes a home visit to a 3-day-old full-term neonate who weighed 3,912 grams (8 lb, 10 oz) at birth. Today the neonate, who is being bottle-fed, weighs 1,350 grams (7 lb, 14 oz).Which of the following instructions should the nurse give to the mother?
- A. Continue feeding every 3 to 4 hours since the weight loss is normal.
- B. Contact the physician if the weight loss continues over the next few days.
- C. Switch to a soy-based formula because the current one seems inadequate.
- D. Change to a higher-calorie formula to prevent further weight loss.
Correct Answer: A
Rationale: The weight loss from 3,912 g to 3,550 g (7 lb, 14 oz) is approximately 9%, which is within the normal range of up to 10% for newborns in the first few days. Continuing regular feedings is appropriate.
When developing the teaching plan for a primigravid client at 30 weeks' gestation diagnosed with mild preeclampsia who is being treated at home, which of the following would the nurse identify as the most appropriate client-centered goal?
- A. Return visit to the prenatal clinic in approximately 4 weeks.
- B. Decreased edema after 1 week of a low-protein, low-fiber diet.
- C. Bed rest on the left side during the day, with bathroom privileges.
- D. Immediate reporting of adverse reactions to magnesium sulfate therapy.
Correct Answer: C
Rationale: Bed rest on the left side enhances placental perfusion and reduces blood pressure.
A primigravid client with insulin-dependent diabetes tells the nurse that the contraction stress test performed earlier in the day was suspicious. The nurse interprets this test result as indicating that the fetal heart rate pattern showed which of the following?
- A. Frequent late decelerations.
- B. Decreased fetal movement.
- C. Inconsistent late decelerations.
- D. Lack of fetal movement.
Correct Answer: C
Rationale: Suspicious results indicate inconsistent late decelerations.
A multigravid client in active labor has been diagnosed with class II heart disease and has had a prosthetic valve replacement. When developing the plan of care for this client, the nurse should anticipate that the physician most likely will order which of the following medications?
- A. Anticoagulants.
- B. Antibiotics.
- C. Diuretics.
- D. Folic acid supplements.
Correct Answer: B
Rationale: Prosthetic heart valves increase the risk of endocarditis during labor due to bacteremia. Prophylactic antibiotics are typically ordered. Anticoagulants may be adjusted, but antibiotics are prioritized during labor.
After teaching the parents of a neonate born with a cleft lip and cleft palate about appropriate feeding techniques, the nurse determines that the mother needs further instruction when the mother says which of the following?
- A. I should clean her mouth with soapy water after feeding.'
- B. I should feed her in an upright position.'
- C. I need to remember to burp her often.'
- D. I may need to use a special nipple for feeding.'
Correct Answer: A
Rationale: Cleaning the mouth with soapy water is inappropriate and could irritate the cleft, indicating a need for further instruction.