Nokea
A nurse is discussing the use of condoms with a female client. Which of the following statements by client represents a need for further teaching?
- A. My partner will put the condom on while his penis is erect.
- B. I will remove the condom 30 minutes after intercourse.
- C. My partner should leave an empty space at the tip.
- D. I can use spermicidal gels or creams to increase effectiveness.
Correct Answer: B
Rationale: The correct answer is B because removing the condom 30 minutes after intercourse is incorrect. Condoms should be removed immediately after ejaculation to prevent leakage or spillage of semen. Leaving the condom on for too long increases the risk of pregnancy and STIs. Choice A is correct as putting the condom on while the penis is erect is the proper way to ensure it fits securely. Choice C is also correct as leaving a small space at the tip allows room for semen collection. Choice D is incorrect because spermicidal gels or creams are not recommended with condoms as they can cause irritation and may not increase effectiveness.
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A woman enters the birthing center in active labor. She tells the nurse that her membranes ruptured 26 hours ago. The nurse immediately takes the client's vital signs. Which is the rationale for the nurse's actions?
- A. Pulse rates rise the longer the membranes are ruptured
- B. Respiratory rates decrease due to lack of fluid in the uterus
- C. Prolonged rupture of membranes can lead to transient hypertension
- D. Infection is a complication of prolonged rupture of membranes
Correct Answer: D
Rationale: The correct answer is D. When the membranes rupture, it increases the risk of infection as it provides a direct pathway for bacteria to enter the uterus. Taking vital signs is crucial to monitor for signs of infection such as fever, tachycardia, and hypotension. Elevated temperature and increased heart rate can indicate an infection. Choice A is incorrect because pulse rate may not necessarily rise with prolonged rupture of membranes. Choice B is also incorrect as respiratory rates are not directly affected by ruptured membranes. Choice C is incorrect as prolonged rupture can lead to infection rather than transient hypertension.
A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure for the newborn?
- A. Apply a cool pack for 10 minutes to the heel prior to the puncture
- B. Request a prescription for IM analgesic
- C. Use a manual lancet blade to pierce the skin
- D. Place the newborn skin to skin on the mother’s chest
Correct Answer: D
Rationale: The correct answer is D: Place the newborn skin to skin on the mother's chest. This technique, known as kangaroo care, helps minimize pain during procedures by providing comfort, warmth, and security to the newborn. The close physical contact with the mother can reduce stress and promote relaxation, leading to decreased perception of pain. Additionally, the release of oxytocin during skin-to-skin contact can further alleviate discomfort for the newborn.
Applying a cool pack (choice A) may actually increase pain and vasoconstriction, making the heel stick more uncomfortable. Requesting an IM analgesic (choice B) is unnecessary and may expose the newborn to unnecessary medications. Using a manual lancet blade (choice C) can be painful and may not provide the same comfort and pain relief as skin-to-skin contact.
A client delivered vaginally six hours ago. Which assessment finding can be interpreted as normal?
- A. Temperature 100.0 degrees F
- B. Blood pressure 140/90
- C. Respirations 10
- D. Pulse 90
Correct Answer: A
Rationale: The correct answer is A: Temperature 100.0 degrees F. This finding can be interpreted as normal because a slight increase in body temperature after childbirth is expected due to the physiological changes during labor. A temperature of 100.0 degrees F is within the normal range for postpartum women.
Rationale for why the other choices are incorrect:
B: Blood pressure 140/90 - This blood pressure reading is slightly elevated and may indicate hypertension, which would not be considered normal postpartum.
C: Respirations 10 - A respiratory rate of 10 is abnormally low and could indicate respiratory distress rather than normal postpartum recovery.
D: Pulse 90 - A pulse rate of 90 may be within normal limits, but it is not as indicative of normal postpartum recovery as a slightly elevated temperature would be.
A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the following actions should the nurse take?
- A. Administer antiviral medication
- B. Schedule an ultrasound examination
- C. Administer Haemophilus influenza type b vaccine
- D. Schedule an indirect Coombs’ test
Correct Answer: B
Rationale: The correct answer is B: Schedule an ultrasound examination. Parvovirus B19 in pregnancy can lead to complications such as fetal hydrops. An ultrasound can monitor fetal well-being and detect any abnormalities. Administering antiviral medication (A) is not typically recommended for parvovirus B19. Administering the Haemophilus influenza type b vaccine (C) is unrelated to this condition. Performing an indirect Coombs' test (D) is used to detect maternal antibodies in Rh incompatibility, not related to parvovirus B19.
A nurse is assessing a newborn following a circumcision. Which of the following should the nurse identify as an indication that the newborn is experiencing pain?
- A. Decreased heart rate
- B. Chin quivering
- C. Pinpoint pupils
- D. Slowed respirations
Correct Answer: B
Rationale: The correct answer is B: Chin quivering. This is a common sign of pain in newborns as they may not be able to communicate verbally. It indicates distress and discomfort. Decreased heart rate (A) and pinpoint pupils (C) are not indicative of pain but rather can be signs of other medical conditions. Slowed respirations (D) can be a sign of distress but not specifically pain. Therefore, B is the most relevant and specific indicator of pain in this scenario.