Nokea
A nurse is discussing the withdrawal method with a client. Which of the following client statements indicates a need for further teaching?
- A. I understand it has a high failure rate.
- B. My partner needs to withdraw before ejaculation.
- C. It provides some protection against STIs.
- D. It requires careful timing and control.
Correct Answer: C
Rationale: The withdrawal method does not provide protection against STIs, indicating a need for further teaching. The other statements are correct regarding its high failure rate, need for withdrawal before ejaculation, and requirement for timing and control.
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A nurse is counseling a client about the use of a diaphragm for contraception. Which of the following instructions should the nurse include?
- A. Insert the diaphragm up to 6 hours before intercourse.
- B. Remove the diaphragm immediately after intercourse.
- C. Use a spermicide with the diaphragm for each act of intercourse.
- D. Store the diaphragm in a dry, airtight container.
Correct Answer: C
Rationale: Using spermicide with the diaphragm for each act of intercourse is essential for effectiveness. The diaphragm can be inserted up to 6 hours before and left in place for at least 6 hours after intercourse but not more than 24 hours. It should be stored in a clean, dry container, not necessarily airtight.
A primigravid client at 39 weeks' gestation is admitted to the hospital for induction of labor. The physician has ordered prostaglandin E2 gel (Dinoprostone) for the client. Before administering prostaglandin E2 gel to the client, which of the following should the nurse do first?
- A. Assess the frequency of uterine contractions.
- B. Place the client in a side-lying position.
- C. Determine whether the membranes have ruptured.
- D. Prepare the client for an amniotomy.
Correct Answer: A
Rationale: Prostaglandin E2 gel stimulates contractions, so assessing baseline contraction frequency ensures it is safe to administer (e.g., no hyperstimulation). Membrane status and positioning are secondary, and amniotomy is not required.
While assessing the fundus of a multiparous client 36 hours after delivery of a term neonate, the nurse notes a separation of the abdominal muscles. The nurse should tell the client:
- A. She will have a surgical repair at 6 weeks postpartum.
- B. To remain on bed rest until resolution occurs.
- C. The separation will resolve on its own with the right posture and diet.
- D. To perform exercises involving head and shoulder raising in a lying position.
Correct Answer: D
Rationale: Diastasis recti often resolves with specific exercises like head and shoulder raises, which strengthen abdominal muscles.
A primigravid client at 39 weeks' gestation is admitted to the hospital in active labor. On admission, the client's cervix is 6 cm dilated. After 2 hours of active labor, the client's cervix is still dilated at 6 cm with 100% effacement at -1 station. Contractions are 3 to 5 minutes apart, lasting 45 seconds, and of moderate intensity. The nurse determines that the client is most likely experiencing which of the following?
- A. Cephalopelvic disproportion.
- B. Prolonged latent phase.
- C. Prolonged transitional phase.
- D. Hypotonic contraction pattern.
Correct Answer: A
Rationale: Lack of cervical dilation (6 cm after 2 hours) despite adequate contractions suggests cephalopelvic disproportion, where the fetal head cannot pass through the pelvis. Prolonged latent phase occurs earlier, transition is at 8–10 cm, and hypotonic contractions are weaker.
A primigravid client at 39 weeks' gestation is admitted in early labor with contractions every 6 minutes. The nurse notes a fetal heart rate of 145 bpm with occasional variable decelerations. What is the nurse's first action?
- A. Notify the physician immediately.
- B. Administer oxygen via non-rebreather mask.
- C. Reposition the client to her left side.
- D. Increase the IV fluid rate.
Correct Answer: C
Rationale: Variable decelerations may indicate umbilical cord compression. Repositioning the client to her left side is the first action to relieve pressure on the cord and improve fetal oxygenation. Notification, oxygen, or increased fluids are considered if decelerations persist.