Nokea
A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions should the nurse include in the plan of care?
- A. Instruct the client to stop taking the antiretroviral medications at 32 weeks of gestation.
- B. Use a fetal scalp electrode during labor and delivery.
- C. Bathe the newborn before initiating skin-to-skin contact.
- D. Administer a pneumococcal immunization to the newborn within 4 hr following birth.
Correct Answer: C
Rationale: Bathing the newborn removes maternal fluids, reducing HIV transmission risk, unlike stopping antiretrovirals (continued), scalp electrodes (increase risk), or pneumococcal vaccine (not routine).
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A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception. Which of the following instructions should the nurse include?
- A. You should wash your diaphragm in gentle soap and water after each use
- B. You should keep your diaphragm in place for at least 4 hours after intercourse
- C. You will use an oil-based vaginal lubricant when inserting your diaphragm
- D. You should have a provider refit you for a new diaphragm
Correct Answer: D
Rationale: Postpartum vaginal changes require diaphragm refitting for effectiveness, unlike incorrect washing (correct but not primary), 4-hour retention (6 hours minimum), or oil-based lubricant (damages diaphragm).
A nurse is performing an assessment of a newborn's Babinski reflex. Which of the following findings should the nurse expect?
- A. Eversion of the great toe
- B. Flexion of the forearm
- C. The downward curl of the toes
- D. Extension of the leg
Correct Answer: A
Rationale: A positive Babinski reflex in newborns shows dorsiflexion and fanning of toes, unlike forearm flexion, toe curling, or leg extension.
A nurse is caring for a client who is at 32 weeks of gestation and has gestational diabetes mellitus. Which of the following findings should the nurse report to the provider?
- A. The client has a fundal height of 38 cm
- B. The client has a fasting blood glucose of 90 mg/dL
- C. The client reports 12 fetal movements in 1 hr
- D. The client has nonpitting pedal edema
Correct Answer: A
Rationale: A fundal height of 38 cm at 32 weeks suggests macrosomia, a gestational diabetes complication, requiring reporting, unlike normal glucose, fetal movements, or edema.
A nurse is providing teaching to a client who is receiving medroxyprogesterone IM for contraception. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will return to the clinic in 8 weeks for my next injection
- B. I will get two shots each time I receive this medication
- C. I should increase my calcium intake while taking this medication
- D. I should discontinue this medication if I experience spotting
Correct Answer: C
Rationale: Increased calcium intake mitigates bone density loss from medroxyprogesterone, unlike incorrect 8-week injections (12 weeks), multiple shots, or stopping for spotting (normal).
A nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery and reports constipation. Which of the following findings should the nurse identify as a contraindication to the use of a suppository?
- A. Abdominal distention
- B. Third-degree perineal laceration
- C. Vaginal candidiasis
- D. Afterpain
Correct Answer: B
Rationale: A third-degree perineal laceration contraindicates suppositories to avoid further trauma and delayed healing, unlike distention, candidiasis, or afterpain, which are not contraindications.